Transcript Perioperative concepts and management

Perioperative concepts and management
Association of PeriOperative Nurses
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AORN
Standards of Care
Recommended Practices
Certification Process: CNOR
Continuing Education
Legislative Issues
RN First Assistant: RNFA
Definition of Perioperative Nursing
 The practice of nursing directed
toward clients undergoing operative
and other invasive procedures
 The perioperative nurse provides
managers, teaches and or studies the
care of clients undergoing operative
or other invasive procedures in all
three phases of the surgical
experience
Practice Areas
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Hospital operating rooms
Interventional radiology suites
Cardiac cath labs
Endoscopy suites
Ambulatory surgery centers
Trauma centers
Pediatric specialty centers
Physician offices
Functions of a Perioperative Nurse
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Advocate
Protector
Teacher
Change agent
Manager of client care
The Surgical Team
Perioperative Team Members
 Nursing Roles in the OR
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Circulating Nurse
Scrub Nurse
RN First Assistant (RNFA)
Perioperative Educator
Specialty Team Leader
Perioperative Manager/Director
Surgical Team
 Behind the scenes
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Radiology Technologist
Anesthesia Technician
Nursing Technician
Transport Team
Environmental Services Team
Perioperative Nursing Skills
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Assessment
Communication
Critical thinking
Technical skills
Surgical Attire
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Gowns
Gloves
Masks
Hair Covering
Protective eyewear
Perioperative Nursing
 Three Phases:
 Preoperative (Preop)
 Intraoperative (Intraop)
 Postoperative (Postop)
Preoperative Phase
 Starts when surgery is scheduled
 Ends when transferred to surgical
suite
 Assessment phase
 Planning phase
 Discharge Planning phase
 Educations phase
 Getting it all together phase
Intraoperative Phase
 Begins when transferred to the surgical
suite
 Ends when transferred to the postanesthesia care unit (PACU)
 Surgical phase
 Anticipatory time
 Maintaining client advocacy
 Maintaining communication with
family/surgical team
 Surgical team interaction
Postoperative Phase
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Begins upon entry to the PACU
Ends when discharge from the PACU
Assessment
Pain control
Education
Discharge planning
Interdisciplinary team communication
Categories of Surgery-Purpose for
Surgery
Defined by:
1. The reason for surgery
2. The urgency for surgery
3. The degree of risk of surgery
4. The anatomic location of the surgery
5. The extent of the surgery required
Reason for surgery
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Diagnostic
Curative
Restorative
Palliative
Cosmetic
Urgency of the procedure
 Elective
 Urgent
 Emergent
Degree of Risk
 Minor Risk
 Major Risk
Anatomic location
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General
GYN
Urology
Orthopedic
Neurological
Plastic
Ophthalmology
Anatomic location
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Cardiac
Thoracic
ENT
Vascular
Transplant
Trauma
Bariatric
Extent of surgery
 Simple
 Radical
Surgical Settings
 Inpatient
 Outpatient/ambulatory
 Hospital-based ambulatory surgery
center
 Free-standing surgical center
 Physician’s office surgery
 Ambulatory Care Centers
Preoperative Period
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Assessment
Nursing Management
Analysis
Planning and Implementation
Evaluation
Collaborative Management
 Preoperative H&P up to 30 days PTS
 Primary Care Physician or Nurse
Practitioner
 Faxed to pre-admission center
 Faxed to PCP or surgeon
 Reviewed, evaluated, changes PRN
 Sometimes surgery gets cancelled
Nursing Process in Pre-op Phase
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Planning:
Correction of any abnormal labs
Blood donations
Bloodless surgery
Nutrition
Pain Management
Surgery Classes
Discharge planning
Assessment
 History
 Surgical Risk Factors
 Physical Assessment and
manifestations
 Psychosocial assessment
 Laboratory/ Radiographic assessment
History
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Present problem, reason for surgery
Past medical history
Past cardiac history
Past surgical history
Family history
Social history
Medications
Allergies
Surgical Risk Factors
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Medical history
Cardiovascular system
Respiratory system
Renal/ Urinary system
Neurological system
Musculoskeletal
Age greater than 65
Surgical Risk Factors
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Medication history
Past surgical complications
Past postoperative complications
Nutritional status
Social habits
Family history of complications
Type of surgical procedure planned
Nursing Physical Assessment
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Health status
Cardiovascular status
Respiratory status
Renal/urinary status
Neurologic status
Musculoskeletal status
Nutritional status
Psychosocial Assessment
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Anxiety
Fear
Coping
Support Systems
Socioeconomic status
Diagnosis
Education
Physical signs
Lab and Radiograph Assessment
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Baseline
Predict potential complications
Abnormal results
Values according to medications
taken
Labs
Urine=UA
Hematocrit=Hct
Hemagloblin=Hgb
White blood cell count=WBC
Prothrombin time/ pro time=PT
Partial thromboplastin time,
activated=aPTT
 International Normalized ratio=INR
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Labs: cont’d
 Chemistry: electrolytes=Na, Cl, K,
Glucose, CO2
 Creatinine
 Blood urea nitrogen (BUN)
 Serum pregnancy test
Radiographs/Optional tests
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Chest x-ray=CXR
Electrocardiogram=EKG
Arterial blood gas-ABGs
Pulmonary function tests=PFTs
Films for area of surgery: x-rays,
MRI, CAT scan
Nursing Management
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Review planned surgery
Obtain client history
Physical assessment
Preadmission treatment/diagnostic testing
Interpret diagnostic tests
Client expectations
Q&A
Caretaker ability
Analysis: Nursing Diagnoses
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Knowledge deficit
Anxiety
Disturbed sleep patterns
Ineffective coping
Anticipatory grieving
Disturbed body image
Disabled family coping
Powerlessness
Planning & Interventions
Dx: Knowledge deficit
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Ensuring informed consent
Client self-determination
Implementing dietary restrictions
Administration of medications
Intestinal preparation
Skin preparation
Vascular access
Pre-operative Teaching
Dx: Anxiety
 Tubes, drains, additional vascular
access
 Post-op procedures
 Post-op exercises: breathing
exercises, incentive spirometry,
coughing & splinting, leg procedures
and exercises
 Early Ambulation
 Range of Motion exercises (ROM)
Relaxation & stress reduction
Dx: Anxiety
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Deep breathing
Music therapy
Touching
Family’s presence
Reassurance
Calm mannerisms
Pre-operative sedation
Collaborative Management:
Assessment & Planning
 Client interview
 Correct person for the correct
procedure with correct preparation
on the correct anatomy
 Risk for perioperative positioning injury
 Lacks normal defense mechanisms
 Size, age skin integrity
 Potential for hypoventilation
 Potential for hemodynamic shifts
 Blood loss
Preoperative Chart Review:
Nursing Responsibility
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Pre-op check list:
Surgical informed consent
Anesthesia informed consent
Blood transfusion consent-T&S done?
Site verification checklist-Med-Surg RN/OR
staff
Lab results-report abnormal lab values
H&P present & signed
Current vital signs
Special Needs
Preoperative Client Preparation
 Clothing removed/don patient gown
 Jewelry removed including body any
piercing/s
 Prosthesis: dentures, wigs, limbs
 Aides: hearing, glasses, cane
 Arm bands: identification, code
status, blood bracelet, fall risk status
bracelet
 Misc: contact lenses, hairpins
 Nail polish, artificial nails
Preoperative Client Preparation
 Empty bladder
 Pre-operative medications:
Versed/Reglan
 Safe transfer to surgical suite
Special Considerations
 Patient’s age: child & elderly
 Cognition: ability to
cooperate/understand
 Ethnic: customs
 Language/communication:
interpreter, HOH
Evaluation: what is my outcome?
Planned or unplanned
 Ms. W, age 77, is admitted for
curative surgery (hysterectomy). She
has a history of asthma & is currently
taking Prednisone. Her weight is 237,
her height 5’3”.
 What are her known risk factors?
 What other questions will you ask?
Critical thinking: Synthesis of
information
 Assessment: physical examination
focused on client’s history & planned
surgery
 Assessment of risk factors
 Client’s previous experience
w/surgery
 Client’s coping resources
 Results of pre-op diagnostic tests
Critical thinking: Synthesis of
information
 Knowledge: A&P of affected body
systems
 Surgical risk factors
 Type of surgical procedure to be
performed
 Surgical stress response infection
control practices
Critical thinking: Synthesis of
information
 Experience: Caring for clients who
have had surgery
 Personal experience with surgery
Critical thinking: Synthesis of
information
 Standards: apply standards of care
(SOC)
 Apply AORN standards in operating
room
 Apply American Society of
PeriAnesthesia Nurses (ASPAN)
standards of care
Critical thinking: Synthesis of
information
 Attitudes: Use discipline in collecting
a complete history
 Use perseverance to ensure a
comprehensive assessment
Goals of Client Safety
 Provide safe client care
 Knowledge of procedure
 Ensure the correct client, correct site,
correct level and correct procedure
 Knowledge of positioning
 Adhere to safe medication administration
guidelines
 Perform surgical counts
Safety: Client
 Correct patient, correct surgery,
correct side: Time Out
 Positioning: padding, alignment,
eyes, breast, penis/scrotum
 Injury: burns
 Sponge, Needle, Instrument counts
 Fall prevention-safety straps
Goals of Client Safety
 Provide a safe environment
 Adhere to asepsis: surgical conscious
 Promote coordinated and effective
communication
Safety: Staff
Sharps
Equipment
Lifting, moving, positioning client
Combative client
Safety equipment: universal protocol:
goggles; isolyzer gel
 OSHA: surgical smoke, laser plume
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Benefits of a Career in
Perioperative Nursing
 Requires
 The ability to work in a fast paced
environment
 Flexibility
 Attention to detail
 Willingness to commit to ongoing
learning
 The ability to work collaboratively as a
member of the surgical team
Patient Outcomes
 Planned Outcomes
 Unplanned Outcomes
Intraoperative Nursing
Break!
Intraoperative Phase
 Begins when the client enters into
the surgical suite
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Sedated?
Aware?
Noises
Cold
Double teamed
Surgical Asepsis
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Surgical field-defined
Surgical tables-green or blue drapes
Surgical conscious
Infection control practices
Physical layout of surgical suite
Protocols: distance, doors, dress
Skin Preparation
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Clip-electric razor
Scrub
Shower
Purpose
Surgical Hand Scrub
 Purpose
 Agents: soap & water vs. liquid hand
cleaner
 Nails
 Position of hands
 Donning gown & gloves
Safety: Staff
Sharps
Equipment
Lifting, moving, positioning client
Combative client
Safety equipment: universal protocol:
goggles; isolyzer gel
 OSHA: surgical smoke, laser plume
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Safety: Client
 Correct patient, correct surgery,
correct side: Time Out
 Positioning: padding, alignment,
eyes, breast, penis/scrotum
 Injury: burns
 Sponge, Needle, Instrument counts
 Fall prevention-safety straps
My Space-Your Space
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Defined geographic locations
Position of equipment
Rules of engagement
Color me blue/green
Surgical conscious
Moving about in the OR
OR traffic patterns
The Red Line
Anesthesia: more choices and
alternatives
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General Anesthesia
Regional Anesthesia
Intravenous Anesthesia
Local Anesthesia
Balanced Anesthesia
General Anesthesia: Inhalation
Agents
 Inhalation most controllable method; lungs act as
passageway for entrance & exit of agent
 Gas Agents : Nitrous Oxide
 must be given with oxygen
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require assisted to mechanical ventilation
frequently shiver
taken in & excreted via lungs
Examples: halothane, enthrane, florane…
Anesthesia Cart
 Supply Cart
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Syringes
IV supplies
Intubation supplies
Medications
Blood transfusion supplies
Regional anesthesia supplies
General Anesthesia
Endotracheal Intubation (maintain
airway patency/promote
oxygenation)
Used with general anesthesia;
Alternatives are mask or LMA
Stages of General Anesthesia
 Stage 1:
Analgesia/Sedation/Relaxation
 Stage 2: Excitement/Delirium
 Stage 3: Operative Anesthesia
 (Stage 4: DANGER: BAD) not
expected/normal
 Speed of EMERGENCE (recovery from
anesthesia) depends on type of
anesthesia, length of time & many
other factors- try to time with end of
surgery
General Anesthesia:
Intravenous
 Intravenous Agents
 Thiopental Sodium (Pentothal) but is
commonly called “Sodium Pentothal” by
patients (class: barbiturate)
 Diprovan (Propofol)
 rapid acting
 monitor vital signs
 respiratory depression
Adjuncts to General Anesthesia
 Hypnotics (Versed)
 also used for conscious sedation
 Opioid Analgesics (Morphine, Fentanyl)
 respiratory depression
 Neuromuscular Blocking Agents
 Causes muscle paralysis
 Examples: Rocuronium, Succinycholine
 What vital function is affected?
Potential General Anesthesia
Complications
 Overdose (consider risk factors)
 Hypoventilation postoperatively
 Intubation related: sore throat,
hoarseness, broken teeth, vocal
cord trauma
 MALIGNANT HYPERTHERMIA
 Genetic predisposition
 Triggered by anesthetics such as
Halothane
Balanced Anesthesia (a sample)
Start with Pentothal or Propofol
Add in some nitrous oxide for amnesia
Use inhalation agent such as halothane
Stir in a little opiate- morphine, fentanyl,
for postop analgesia
 To top it off give Pavulon, a neuromuscular
blocker, for additional muscular relaxation
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Regional Anesthesia
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Field Block
Nerve Block
Spinal Anesthesia
Epidural Anesthesia
Regional Anesthesia
 Loss of sensory nerve impulses;
motor function may or may not be
affected
 No loss of consciousness
 Field Block: “caine” injected around a
nerve or group of nerves (dental
procedures)
 May be combined with epinephrine to
prolong
 Approximately 30 min to 2 hours
Regional Anesthesia: Spinal
 Local anesthetic
(-caine) injected
into cerebrospinal
fluid (approx L 35) subarachnoid
space
Spinal Anesthesia (Subarachnoid
Block)
 Anesthesia: tip of xiphoid to toes
 Risks:
 Loss of vasomotor tone
 “Spinal Headache”
 Infection, Rising anesthesia above
diaphragm
 Nursing: KEEP FLAT, MONITOR VS &
OFFER FLUIDS WHEN APPROPRIATE
Regional Anesthesia: Epidural
 Injected into epidural
space rather than
subarachnoid fluid
(usually safer)
 Used for OR & OB
 Epidural catheter can
be left in place for
postop pain
management (PCA)
Regional Anesthetic Risks
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Anaphylaxis (ALLERGY)
Incorrect administration technique
Systemic absorption of medication
Infection
Intravenous Anesthesia
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Multiple Agents
Multiple Purposes:
Induction
Hypnosis
Dissociative
Opioid Analgesics
Neuromuscular blocking agents
Conscious Sedation
 Reduce intensity of pain without loss of
defensive reflexes
 Usually a combination of opioid analgesic
and sedative-hypnotics
 May be administered by credentialed RN
 Expect client to be sleepy but arousable
 JUST BECAUSE HIS EYES ARE CLOSED
DOESN’T MEAN HE’S ASLEEP!!
Local Anesthesia
 Local/Topical
 Interrupts transmission of
sensory nerve impulses so
it: numbs what it touches
 Requires multiple injections
with “CAINE” drug
(Example: novacaine,
lidocaine)
 Duration = 1 min to 20-30
min
-Can be prolonged with
added epinephrine
 Assess for ALLERGY
*Nursing Process during the
Intraoperative Phase
 Assessment-ongoing
 Planning
 Proactive
 Flexible
 Forever Changing
Nursing Process Intraop Phase
 Evaluation
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Expected
Unexpected
Documented
Informing Client & Family
Surgical Waiting Room
Ongoing Updates by OR Team
Postoperative Goals
 Re-establishment of physiologic
equilibrium
 Alleviation of pain
 Prevention of complications