Transcript Nursing Management of Clients with Peri

Nursing Management of
Clients with
Peri-Operative Stressors
NUR133
Lecture #2 & #3
K. Burger, MSEd, MSN, RN, CNE
What is Medical-Surgical Nursing?
Blend of technical skills & caring
relationships
Specialty of nursing
Nursing care of adults 18yrs +
Requires broad scope of knowledge
Encompasses many roles/competencies
Academy of Medical-Surgical Nurses
(AMSN)
= specialty organization
Take some time to…
Review the Academy of Medical Surgical
Nurses (AMSN) website @
http://www.medsurgnurse.org
Click on and read:
Learn more about Medical Surgical Nursing
What are your opinions about the role of
the medical surgical nurse as outlined in
this AMSN statement?
Peri-Operative Nursing
 SURGERY
DEFINITION = A planned alteration of
physiologic processes within the body in an
attempt to arrest or eliminate disease or illness
 PHASES =
Pre-operative
Intra-operative
Post-operative
Goal of Peri-Operative Nursing
To prepare the client mentally and
physically for surgery and to assist in full
recovery in the shortest time possible with
the least discomfort.
Classifications of Surgery
PURPOSE
Diagnostic
Curative
-Ablative
-Restorative
-Reconstructive
Palliative
Cosmetic
Transplant
URGENCY
Elective
Urgent
Emergency
SERIOUSNESS
Minor
Major
Variables Affecting
Surgical Outcome
 Age
 Nutrition
 Fluid Balance
 Life-style Habits
 Medical Conditions
 Medication History
 Family History
 Prior Surgical Experiences
 Spiritual and/or Cultural Beliefs
 Anxiety and Coping Mechanisms
Pre-Operative Phase
Begins when a decision is made to
perform a surgical procedure and ends
when the client enters the operating room
Nursing goals =
Assessing for risk factors
Emotional support of client
Client teaching
Physical preparation of client
Pre-operative Nursing Assessment
HISTORY
Age
Medication
Medical history
Allergies
Prior surgeries and outcomes
Anesthesia history / personal & familial
Lifestyle habits: alcohol / smoking/ exercise
Pre-operative Nursing Assessment
PHYSICAL
 VS
 Head & Neck
 Skin Turgor
 Thorax & Lungs
 Heart & Vascular System
 Abdomen
 Neurological Status
Pre-Operative Nursing Assessment
LABS
DIAGNOSTICS
Complete Blood Count
(CBC)
Basic Metabolic Panel
(BMP)
Coagulation Studies
PT/PTT
Urinalysis
Blood typing / screening
Additional tests as indicated
Chest X-Ray
(CXR)
Electrocardiogram
(ECG)
Additional tests as indicated
LABORATORY NORMALS
 Students should research/fill-in/memorize the
following lab values ( See pg 302-303 Iggy)
K
Na
Cl
FBS
BUN
Cr
WBC
Hgb
Hct
Pre-operative Nursing Assessment
Knowledge
Informed Consent
Anxiety
Coping mechanisms
Availability of support
Common Pre-operative
Nursing Diagnosis
Anxiety r/t situational crisis, change in
health status, fear of unknown, fear of pain
and/or disfigurement
Knowledge deficit r/t pre/post operative
procedures
Disturbed Sleep r/t anxiety about
upcoming surgery
Pre-operative Nursing Interventions
Emotional Support
Utilize positive communication techniques
touch – eye contact
validating statements
Active listening
Encourage verbalization of fears/anxieties
Avoid negative communication techniques
false-reassurance
judgmental statements
Pre-Operative Nursing Interventions
Client Teaching
Peri-operative progression & sensations
Description of Pre and Post operative events
Description of events in OR and PACU
Pain management
Coughing & Deep Breathing Exercises
Incentive Spirometry
Turning & Positioning
Leg Exercises & Ambulation
Client Teaching
Pain Management
Pre-operative assessment of individual
pain perception on 1-10 scale
Reassurance that pain reports WILL be
believed and acted upon
Use of PCA
Benefits of ATC versus PRN
Allaying of fears regarding addiction
Potential side-effects of narcotics
How pain management promotes recovery
Client Teaching
Pulmonary Exercises
Method for diaphragmatic breathing:
Hands on ribs, inhale thru nose allowing
abdomen to expand, hold 3-5 sec, exhale
thru pursed lips, 10X /hr while awake
Method for controlled coughing
Deep breath X2 , then inhale,
hold breath 2-3 sec, cough
forcefully 2-3X consecutively
Method for splinting
Client Teaching
Pulmonary Exercises
Instruction on use of Incentive Spirometer:
Take 2-3 normal breathes, close lips on
mouthpiece, inhale to reach set goal, hold 35 sec, release mouthpiece & exhale, 10X/hr
while awake.
Client Teaching
Activity
 LEG EXERCISES
Dorsi/Plantar flexion, ankle rotation, knee/hip
flexion, 5X each leg/hr w.a.
 AMBULATION
Discuss importance of early ambulation and
method for getting out of bed
 TURNING AND POSITIONING
Use of side rails
 External pneumatic compression devices
(Sequentials, SCDs, Flowtron)
Pre-operative Nursing Interventions
Physical Preparation of Client
Implementing dietary restrictions
Initiation of surgical preps
Insertion of tubes/drains/vascular access
Completion of pre-operative checklist
Administration of pre-operative medication
Pre-operative Nursing Responsibilities
Medical Record Review
Informed Consent
History and Physical
Medical Clearance
Advance Directives
Allergies / Previous anesthesia reactions
Presence of autologous blood bank
Labs and Diagnostics
Intra-Operative Phase
Begins when client arrives in surgical area
and lasts until they are in the PACU
Nursing Goals =
Prevention of injury to client
Maintenance/Promotion of: oxygenation,
cardiac output, balanced I & O
The Intra-operative Team
Surgeon
Surgical Assistants: MD, PA, ST
Anesthesiologist and/or Nurse Anesthetist
Registered Nurses: Circulating, Scrub
Anesthesia
Anesthesia is defined as the absence of
normal sensation. This also includes loss
of protective reflexes!
Anesthesia provides:
amnesia – analgesia – muscular relaxation
Stages I-IV of Anesthesia ( Guedel’s Signs)
Types:
General
Local
Conscious Sedation
General Anesthesia
 Inhalation
 Intravenous
 Balanced = use of both
 Mechanical Ventilation – presence of ET tube
 Use of adjuvant medications such as:
Hypnotics: Versed
Opioids: Fentanyl
Neuromuscular Blocking Agents: Pavulon
Anectine
Important Factors in the
Care of the Anesthetized Client
Use protective positioning techniques
Handle gently
Change positions slowly
Keep client warm
Potential Complications of
General Anesthesia
Overdose
Unrecognized hypoventilation
Complications of intubation
Anaphylaxis
Hypothermia
Injury r/t positioning, burns
Malignant hyperthermia
Malignant Hyperthermia
Rare but extreme emergency
Occurs most often with inhalants
Genetic predisposition
 Uncontrolled acceleration of muscle
metabolism and increased BMR
Life threatening elevated temperature,
hyperkalemia, acidosis
Emergency Treatment of
Malignant Hyperthermia
Stop surgical procedure/anesthesia if
possible
Hyperventilate with 100% oxygen
Administer DANTROLENE intravenously
Undertake body cooling measures:
Iced NS intravenously
Cooling blanket
Local Anesthesia
Advantages
 Client remains
conscious
 Cost effective
 Minimal recovery time
 Vasoconstrictive
agents decrease
bleeding
Disadvantages
 Client remains
conscious
 Potential for local
tissue irritation
 Potential for sudden
systemic reaction
such as hypotension
Regional Anesthesia
Types
Field Block
Injected around the operative field
Nerve Block
Into or around a nerve or nerve group
Spinal
Into subarachnoid space
Epidural
Into epidural space
Regional Anesthesia
Advantages
 Patient remains
conscious
 No respiratory
depression or
irritation
 Enhanced pain
management postoperatively
Disadvantages
 Patient remains
conscious
 Circulatory
depression/stasis
 Potential
trauma/infection @
site of injection
 Edema - potential for
spinal headache
Conscious Sedation
IV administered hypnotic, opioid, or
sedative
Reduces LOC but does not produce
unconsciousness
Airway maintained
Client can respond to simple commands
Provides short amnesia action
Commonly used for: scopes, caths etc.
Intra-operative Nursing Diagnosis
Risk for positioning Injury
Risk for Fluid Volume Imbalance
Risk for Hyperthermia
Potential for Hypoventilation
Risk for Aspiration
Risk for Impaired Skin Integrity
(see EBP page 335 Iggy)
“Pressure ulcers do occur in surgery”
Post-Operative Phase
Begins upon admission to the PACU and
continues through entire recovery phase
Nursing Goals =Promoting physiological
recovery of all body systems, prevention of
complications, pain management,
client teaching and
emotional support
Focused Assessment
in PACU
 Respiratory – patent airway, + O2 status
(Most common PACU complication)
 CNS – monitor gradual return of function
 Surgical Incision site – bldg? drainage?
 Vital Signs – cardiac function
hypothalmus depression
 GI- nausea/vomiting common, aspiration risks
 GU- strict Intake and Output, check for retention
 Comfort – administer analgesia IV per MD
orders
Discharge Criteria
PACU
(Modified Aldrete Score)
 Consciousness
2 = Fully awake
1 = Responds to name
0 = No response
 Activity on command
2 = Moves all extremities
1 = Moves two extremities
0 = No movement
 Respiration
2 = Free deep breathing
1 = Dyspneic, hyperventilating, obstructed breathing
0 = Apneic
 Circulation
2 = Blood pressure within 20% of pre-op level
1 = Blood pressure within 50%–20% of pre-op level
0 = Blood pressure 50%, or less, of pre-op level
 Oxygen saturation
2 = SpO2 >92% on room air
1 = Supplemental O2 required to maintain SpO2 >92%
0 = SpO 2 <92% with O2 supplementation
 Total Score
10 = Score = 9 needed to leave PACU
Focused Assessment
for Post-Operative Client
Upon arrival on Nursing Unit
 VS – compare against PACU data, take frequently until
stable
 Respiratory status: auscultate, pulse ox
 Cardiac status: HR – peripheral pulses
 LOC
 Skin – surgical site and other areas
 Abdomen – listen for return of bowel sounds
check for distention ( flatus vs urine)
 Tubes – IV, NG, Drains, Foley
 Comfort – Administer analgesics; check PACU record
Nursing Diagnosis
Post-Operative Clients
Acute Pain
Risk for Ineffective Tissue Perfusion r/t
hypovolemia, circulatory stasis
Risk for Ineffective Breathing Pattern r/t
pain, effects of anesthesia/narcotics
Risk for Infection r/t invasive procedure,
respiratory stasis
Risk for Deficient Fluid Volume r/t fluid
losses during surgery
Post-Operative Nursing Interventions
Prevention of complications:
Respiratory:
-Assess for s/s pneumonia, atelectasis,
pulmonary embolus
-Encourage C & DB and Incentive Spiro
-Position with HOB elevated
-Encourage ambulation
Post-Operative Nursing Interventions
Prevention of complications
Cardiovascular:
-Assess for s/s hemorrhage, shock,
thrombophlebitis
-Utilize sequential TEDs
-Encourage leg exercises and/or
ambulation
-Position to promote venous return
Post-operative Nursing Interventions
Preventions of complications
Elimination:
-Assess for s/s of constipation, urinary
retention, ileus, UTI
-Encourage ambulation
-Maintain IV and/or PO fluid intake
-Provide privacy, proper positioning and
other strategies to promote elimination
Post-Operative Nursing Interventions
Prevention of Complications
Wound:
-Assess for s/s of infection, dehiscence,
evisceration
-Promote wound healing through careful
aseptic handling
-Encourage balanced diet w/ sufficient
protein, Vit C, Iron, Zinc
- Administer prescribed antibiotics
Antibiotic Medications
 Students should research the following classes of
antibiotics for important nursing implications of each:
(Chapter 37 & 38 Lilley)
Penicillens
Cephalosporins
Sulfonamides
Tetracycline
Aminoglycosides
Quinolines
Macrolides
Carbapenems
Miscellaneous
Ex: Unasyn
Ex: Rocephin
Ex: Bactrim
Ex: Vibramycin
Ex: Gentamicin
Ex: Levaquin
Ex: Erythromycin
Ex: Imipenem
Ex: Vancomycin
Post-operative Nursing Interventions
Comfort and Rest:
Pain management
Keep linens clean and dry
Provide for personal hygiene needs
Keep environment quiet
Post-operative Nursing Interventions
Fluids and Nutrition:
Monitor I & O
Provide good oral hygiene
Ice chips / water sips
Assess for return of peristalsis
Assess for gag reflex
Gradual diet progression – clear, full, soft
Post-Operative Nursing Interventions
Emotional support
-Encourage expression of feelings
-Utilize positive communication techniques
Knowledge deficit
-teach wound care, s/s infection, dietary
recommendations, activity restrictions,
medication regime
Transfusion Therapy
 Pretransfusion responsibilities:
Verify prescription and other concommitant orders
Test donor’s and recipient’s blood for compatibility
ABO and Rh TYPE & CROSSMATCH
Obtain consent and apply “blood bracelet”per hospital
policy
Determine patency of IV AND angiocath lumen
(20gauge minimum)
Collect supplies:
250 mL bag Normal Saline
Y-set blood tubing with filter
Pre-Tranfusion Responsibilities
Obtain blood product from lab per protocol
With another nurse confirm:
- physician order
- client identification
- blood bag label, attached tag, and requisition
slip for ABO and Rh compatability
- client blood bracelet matches blood bank
number on unit of blood to be administered
-expiration date
Inspect blood for discoloration, gas bubbles,
or cloudiness.
Transfusion Responsibilities
 Assess vital signs.
 Prime Y-tubing with NS
Gently agitate blood bag
Spike and attach blood bag
 Begin transfusion slowly and stay with client first 15
minutes. Take VS Q 5 minutes.
 Ask client to report unusual sensations such as
chills, shortness of breath, hives, or itching.
 After 15 minutes without reaction increase flow rate
to administer blood product per agency protocol.
(usually 11/2 hr – 2 hrs for PC)
 Continue to monitor client closely with VS q 15-q30m
 Flush line with NS after infusion is complete
Types of Transfusions
Packed red blood cells
Platelets
Plasma transfusions: fresh frozen
plasma
Cryoprecipitate
Granulocyte (white cell) transfusions
Transfusion Reactions
Clients can develop any of the
following transfusion reactions:
Hemolytic
Allergic
Febrile
Bacterial
Circulatory overload
Iron overload
Hypocalcemia
Hyperkalemia
NURSING INTERVENTIONS
STOP TRANSFUSION
CHANGE IV TUBING
KEEP IV PATENT WITH NS
NOTIFY MD
Autologous Blood Transfusion
Collection and infusion of client’s own
blood
Eliminates compatibility problems;
reduces risk for transmission of
bloodborne disease
Preoperative autologous blood
donation
Intraoperative autologous transfusion
Postoperative blood salvage