PERIOPERATIVE CARE Ignatavicius, 6 th edition/ Chapters 20-22 Jerry Carley, MSN, MA, RN, CNE Jose Perez 1992* *There are three other works by this artist

PERIOPERATIVE CARE Ignatavicius, 6 th edition/ Chapters 20-22 Jerry Carley, MSN, MA, RN, CNE Jose Perez 1992* *There are three other works by this artist in the nursing department.

Waking Up Is Hard to Do http://www.youtube.com/watch?v=WOrjcLJ2IE0

Objectives Differentiate between the types and purposes of surgery Identify factors that increase the clients risk for complications during and immediately following surgery Discuss a preoperative assessment of the clients physical and psychosocial status Describe proper procedure for obtaining informed consent Recognize client conditions that need to be communicated to the surgical and postoperative teams Describe and identify safe nursing interventions during the perioperative period

Objectives Intra-operative Discuss interventions to reduce client and family anxiety Describe the roles and responsibilities of intra-operative personnel Discuss nursing interventions to prevent skin breakdown for older clients during surgery Discuss complications from anesthesia Explain specific problems related to positioning during surgical procedures

Objectives for Postoperative Describe the ongoing head-to-toe assessment of the postoperative client Prioritize nursing interventions for the client recovering from surgery and anesthesia during the first 24 hours Discuss the criteria for determining readiness of the client to be discharged from the post anesthesia care unit (PACU) Discuss wound complications after surgery

Key Terms Preoperative Intra-operative Postoperative Atelectasis Anuria Dysuria Oliguria Adipose Nosocomial Hypoxia Aspiration Homans sign Dehiscence Evisceration LOC

Preoperative Care Preoperative care begins when the client is scheduled for surgery, and ends at the time of transfer to pre- anesthesia care unit or O.R. Suite

Purposes of Surgery Diagnostic: determine origin and cause Curative: resolve a health problem Restorative: improves client function Palliative: relieve symptoms Cosmetic: alter or enhance personal appearance

Urgency of Surgery Elective: planned and non-acute Urgent: prompt intervention, life threatening if delayed 24-48 hours Emergent: immediate intervention, life threatening

Degree of Risk Minor: procedure with less risk; often completed with local anesthesia Major: procedure with greater risk, longer, more extensive than minor

Collaborative Management Assessment History and data collection: -age -drugs and substance abuse -medical history and current medications -previous surgery and anesthesia (family history) -blood transfusions or donations -Allergies -discharge planning

Medical History Chronic and acute illness can increase surgical risk -Cardiac: anesthesia and medical complications: CAD, MI, angina, hemodynamic changes -Respiratory: pulmonary complications: smoker, asthma, emphysema, pneumonia

Current Medications Medications can adversely affect the outcome of surgery -Antidysrhythmics -Antihypertensive -Corticosteroids -Anticoagulants -Antiseizure -Antidiabetic Remember herbs and over the counter drugs (OTCs) are important as are Nutraceuticals

Surgery and Anesthesia Family and clients history of reactions to anesthesia medications!!!!!!!! ALLERGIES Previous blood transfusions: history of any reactions are IMPORTANT!

Assessment Complete Head to Toe Assessment (baseline) Review all systems: -Cardiovascular -Respiratory -Neurological -Renal/Urinary -Gastrointestinal -Musculoskeletal -Psychosocial -SKIN Vital Signs (baseline)

Assessment Labs: -CBC, electrolytes, coagulation studies, type and screen, pregnancy test, UA Radiographic: -chest x-ray, CT scans, and MRI Diagnostic: -EKG and ultrasound Nutritional Status: malnutrition & obesity

Nursing Diagnoses Knowledge Deficit Anxiety Risk for infection Risk for pain Altered urinary elimination Risk for impaired skin integrity Powerlessness Disturbed body image Ineffective coping Disturbed sleep pattern

Interventions Education (Pre-op teaching)* -informed consent -dietary restrictions -specific preparation (e.g., bowel prep) -post op instructions: exercise, plans for pain management, incentive spirometer, cough and deep breathing, splinting abdomen Ensure client understands surgery, outcomes and what to expect

Informed Consent Consent implies the client has been given sufficient information to understand; -the nature of and reason for surgery -know the surgeon performing surgery and others that may be present during procedure* -all available options and risks -risks of surgery and potential outcomes -risk associated with anesthesia

Informed Consent Physicians responsibility: -inform patient of surgical details (reason, options, & risk etc.) -have document signed prior to sedation being given Nurses responsibility: -ensure consent is signed by the patient -acts as a witness to clients signature ONLY

Preparation for Surgery Dietary restrictions: -NPO for 6-8 hours* (exception for medications with sips of H2O) -NO drinking, eating, or smoking -to decrease risk of aspiration/atelectasis

Preparation for Surgery Medication administration: -May be altered or given with sip of water -Notify MD if patient is on any antihypertensive, anticoagulants, antiseizure, antidepressants, corticosteroids, or insulin

Preparation for Surgery Intestinal prep: -may be needed if client is having abdominal, pelvic, perineal, perianal surgery -reduces injury to colon -decreases intestinal bacteria Skin prep: -first step to reduce risk of infection -sometimes done in the operating room holding area

Preparation for Surgery Tubes: -indwelling catheter: bladder empty and monitor renal functioning -nasogastric: decompress &/or empty stomach Vascular access: -peripheral or central line -allows administration of fluids and medications

Preoperative Teaching Prepare the client for post op period -breathing exercises -incentive spirometry -coughing and deep breathing -Leg procedures: TED, ace wraps, sequential compression devices (SCDs) **(PREVENTS DVT) ** -Type & Crossmatch # units -early ambulation -ROM exercises

Preoperative Chart Review Ensure completion Pre-Operative Checklist Documents: surgical & blood consent, & anesthesia report Orders: NPO, labs, x-rays, IV access, foley, NG tube, IVF, and medications etc. Pre-op procedures: EKG & ultrasound Accurate ht and wt* must be obtained Check procedure schedule REPORT ANY PROBLEMS, NEEDS, or CONCERNS

Client Pre-op Preparation Client should be wearing only a gown: all undergarments are removed (some exceptions) Leave valuables at home or with family Tape rings if they can not be removed Remove dentures, partials, and plates Remove all prosthetic devices ID and allergy band on wrist Blood Bands if applicable ? Nail polish ?

Preoperative Medication Reduce anxiety Promote relaxation Reduce pharyngeal secretions Prevent laryngospasms inhibit gastric secretions

Preoperative Medications Sedatives (benzodiazepines) Narcotic analgesics (opioid) Anticholinergics (atropine) Antiemetic agents Antacids or H2 receptor blockers IVs Blood products (only run with NS) Antibiotics for surgical prophylaxis

Intra-operative Members of surgical team include but not limited to: -surgeons -surgical assistants -anesthesiologist -certified registered nurse anesthetist -operating room technicians -surgical technologist -holding area nurses -circulating nurse -scrub nurse

Environment of Operating Room Ways to reduce bacteria level: -cool temperature -limited traffic -personnel wearing sterile & protective attire -personnel uses surgical scrub

Anesthesia Induces state of partial or total loss of sensation, occurring with or without consciousness Used to block nerve impulse transmission, suppress reflexes, promote muscle relaxation, and in some instances achieve a controlled level of unconsciousness

Complications from Anesthesia Cardiac arrest Anaphylactic reactions Malignant hyperthermia Massive blood loss Dysrhythmias Aspiration Overdose Unrecognized hypoventilation Complications with intubations

Intra-operative Nurse Responsibility Monitor airway and clients O2 saturation Constant monitoring of heart rhythm, rate, and BP Monitor temperature Monitor IV access, drains, tubes, and catheters, I&O Assessment of sedation level and anesthesia

Intra-operative positioning Risk for peri-operative positioning injury related to immobilization and effects of anesthesia Circulating nurse coordinates positioning and modifies to reduce the risk of skin, nerve, joint damage and muscle strain or stretching

Postoperative PACU: Post-anesthesia Care Unit: -Purpose is to provide ongoing evaluation and stabilization of the clients and to anticipate, prevent, and treat complications after surgery -Discharge is based on stability of client (recovery score)

Postoperative Assessment Complete assessment of ALL systems Examine surgical site for bleeding Assess for readiness to discharge client after criteria have been met Measure I & O (especially urine output!!!) Goals: -return client to normal physiologic functioning following anesthesia -Maintain asepsis -Manage pain -Prevent post op complications

Postoperative Assessment Post anesthesia stage, client must be continually assessed for airway patency and adequate ventilation

Respiratory Assessment Patent AIRWAY and adequate GAS EXCHANGE Monitor breath sounds, rate, depth, oxygen saturations and pattern Rate less than 10/minute, anesthetic depression or opioid induced Inspect chest wall for accessory muscle use, sternal retractions, and diaphramatic breathing

Cardiovascular Assessment Vital signs (at least) every 15 minutes until stable* Listen to heart sounds, assess rate, rhythm, and quality Assess for Dysrhythmias via continuous cardiac monitoring Observe for signs of bleeding, check site frequently Peripheral vascular assessment (age matters!) Check pulses, color, temperature, sensation, and capillary refill of all extremities (especially lower extremities)

Neurological Assessment o Assess LOC: o -observe for lethargy, restlessness, irritability, and test coherence and orientation o Motor and sensory: o -follow simple commands and moves all extremities o -numbness and tingling o -sympathetic nervous system: gradually elevate head and monitor for hypotension

Fluid and Electrolytes Balance Check and evaluate fluid and electrolyte balance Assess fluid volume: overload vs. deficit Monitor I&O Observe mucus membranes, skin turgor, texture, drainage, and perspiration

Renal/Urinary System Indwelling catheter monitor output, clarity, color, and amount* No indwelling catheter or removed: observe for urinary retention (how?) Urine output should be greater than 30cc/h or 200cc every 6 hours

Gastrointestinal Assessment Assess for bowel sounds, flatus, tenderness, and distention Monitor S&S of nausea and vomiting NPO until gag reflex is present, risk for aspiration Assess and monitor NG tube -check placement and patency -observe drainage, color, and amount

Nasogastric Tube May be inserted prior or during surgery to decompress or drain stomach or reduce risk or aspiration -promote gastrointestinal rest -allow lower gastrointestinal tract to heal -provide enteral feeding or medication

Skin Assessment Assess surgical wound: -surgical dressing remains for 24-48 hours -MD will remove first dressing* -observe for bleeding or drainage on dressing Check skin for breakdown** Monitor drains: color, amount, consistency, and odors

Pain Assessment Client almost always has pain after surgery: -pain related to: incision, tissue manipulation, drains, positioning, and tubes Assess physical and emotional signs of pain -increased pulse, BP, respiratory rate, profuse sweating, restlessness, wincing, moaning, and crying Plan activitys around pain management to ensure patient has optimal pain relief during activities

Laboratory Assessment Electrolytes CBC Left-Shift -early sign of infection -increase in immature neutrophils ABGs Urinalysis

Risk Factors for Postoperative Complications Pre-existing heart, respiratory, neurological, renal or blood disorders Diabetes (BS greater than 80-110 mg/dl) Steroid therapy Obesity (BMI>30) Poor nutrition History of substance abuse Immobility Anemia Hypovolemia Coagulation defect ETOH abuse/history

Postoperative Complications Respiratory: -Inadequate airway and /or poor ventilation -Obstruction -Hypoxia -Pneumonia -Aspiration -Pulmonary edema -Exacerbation of CHF -Laryngospasms

Postoperative Complications Cardiac / cardiovascular: -Hypovolemic shock -Dysrhythmias -DVT

Postoperative Complications Gastrointestinal: -Wound dehiscence and evisceration -Nausea and vomiting -Paralytic Ileus Ileus

Postoperative Complications Dehiscence: partial or complete separation of the outer wound layers, sometimes described as splitting open of the wound Evisceration: total separation of all wound layers and protrusion of internal organs through the open wound

Postoperative Diagnosis Impaired gas exchange Impaired skin integrity Acute pain

Postoperative Interventions Airway maintenance Coughing & deep breathing Inspirometry Positioning and mobilization DVT prophylaxis Wound and drain care Drug therapy (pain medication administration)

Health Teaching Prevention of infection (such as?) Care and assessment of surgical wound * Diet therapy Pain management Drug therapy Progressive increase in activity

Postoperative Evaluations Attains and maintains adequate lung expansion and respiratory function Has complete wound healing without complications Has acceptable comfort levels after surgery (what level of pain is acceptable?)

Home Management Assess home environment Determine clients needs Assist devices may be needed Educate on postoperative concerns: -assessment and care of wounds -S&S of infection -pain medication and side effects -constipation prevention

Conscious SedationModerate Sedation See the Case Study