Transcript Perioperative Care

Inflammation Concept:
Perioperative Care
Brunner ch.17-19
Review of Inflammation: What It
Is and What It Isn’t
The body’s cellular response to injury,
infection, or irritation.
 Mechanism is the same regardless of
injuring agent.
 Always present with infection.
 It is not infection. Infection is not always
present with inflammation.
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Inflammatory Response
Intensity depends on extent and
severity of injury & body’s ability to react
 Sequential:
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– Neutralizes & dilutes inflammatory agent
– Removes necrotic materials
– Establishes an environment suitable for
healing and repair
Causes of Inflammatory
Response
Heat—burn injury
 Radiation—sunburn, radiation tx
 Trauma—surgery*
 Allergens—sinuses; anaphylactic shock
 Infection
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Steps of Inflammatory Response
Vascular response
 Cellular response
 Formation of exudate
 Healing
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Manifestations of Inflammation
Localized response (redness, pain,
swelling, etc) and systemic response
(increased TPR, malaise, nausea,
anorexia, etc) are the same as in the
infectious process (see Infection
Concept Lecture)
 With a high degree of inflammation, and
when infection is present, WBCs rise
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Healing Process
Regeneration—replacement of lost cells
and tissues with cells of same type
 Repair—replacement of lost cells with
connective tissue (scar)
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Exemplar: Perioperative Care
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Good example of inflammation because
inflammation is the body’s response to
trauma and surgery is considered a type of
trauma.
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Normal postoperative wound healing is an
excellent example of the inflammatory
process in action.
Stages of Perioperative Care
– Preop—from time of admission to time of
transfer to OR
– Intraop—from time of transfer to OR to time
of transfer to PACU
– Postop—from time of transfer to PACU to
time of discharge from hospital
Preoperative Legal and Ethical
Considerations
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Informed consent (407)—MD and
nurse’s responsibility. Pt needs:
– Adequate disclosure
– A clear understanding
– To consent voluntarily
Transfusions—may or may not be part
of the general form
 Mental competency/Minors
 Advocacy
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Surgical Patient—Preoperative
Risk Factors
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Age—elderly and children
Nutrition—malnourished and obese
Smoking
Chronic diseases
Physical disabilities
Medications
Allergies
Patient classification acc’d to ASA (424)
Home Risk Factors
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Support systems
Physical layout
Hygiene
Smoking
Nutrition
Traffic control
Distance
Transportation
Preop Assessment
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Health hx
VS, pain, pulse ox, anxiety
Focus on CV, respiratory systems, and
surgical area
Diagnostics—labs and radiology
Dietary considerations—NPO
Surgical preps needed
Education needed
Patient Needs
Psychosocial needs—fears, therapeutic
communication, referrals, spiritual and
cultural needs, support systems, body
and self-image and lifestyle changes
that could occur, past experiences
 Developmental needs—children and
elderly
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Preoperative Medications
Given in holding area or “On call”
 Sedatives—induce sedation, amnesia
 Anxiolytics—reduce anxiety
 Antibiotics—prevent, treat infection
 Histamine blockers—reduce secretions, increase
motility
 Anticholinergics
 Pain meds, antiemetics
 Eye gtts
 Routine Rxs
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Provide Education
Teach to senses
 Postop pain control
 Professional roles
 Prevention of complications
 Equipment
 Family
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Document
Preop checklist (417)
 Preop assessment (may be on flow
sheet or nurse’s notes)
 Consent forms on chart
 Check computer to make sure other
necessary reports are on chart
 Transfer to OR
 Finish charting before transfer
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Intraoperative Team
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Circulating nurse(RN)—In charge of activities,
safety and verification, equipment, traffic flow,
contacts, patient assessment, preop meds, IV start,
counts, Safety Checklist (423) etc.
 Scrub nurse or tech—sets up sterile fields,
hands-off to surgeon, labels tissue, counts
 RN first assistant—surgeon’s “right hand”, does
some simple surgical tasks
 Surgeon—head of team, may have others
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Anesthesiologist/CRNA (ACP)—gives
anesthesia, monitors physiologic functions
OR Environment
3 levels: unrestricted, semi-restricted,
restricted
 Aseptic practices
 Preventing complications and injuries
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– Electrical and fire
– Mechanical
– Hypothermia
– Hyperthermia
Types of Anesthesia(427):
General
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Given IV or by inhalation. Induces deep
sedation (Stage III)—causes loss of
consciousness and reflexes—pt will need
ventilatory support
 Given for long procedures, when total muscle
relaxation is needed, when pt is extremely
anxious, or if pt is uncooperative or refuses
other types.
 Advantages: rapid induction
 Disadvantages: CV and respiratory SEs
Regional & Local
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Local—loss of sensation without loss of
consciousness. May be topical or by injection
 Regional (nerve blocks, spinal, epidural)—
loss of sensation without loss of
consciousness. See diagram p. 432
 Advantages—little systemic absorption; rapid
recovery; good for hi-risk pts
 Disadvantages—technical difficulty, HA,
discomfort, hard to match anesthesia with
length of surgical procedure
IV Conscious Sedation
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Also called Moderate Sedation
Used for routine procedures
Reduces anxiety, controls pain
Produces amnesia
Patient will still have patent airway and be
able to follow commands
Pt must be monitored (CV, resp, LOC)
Must be given by someone specially trained
Recovery is quick
Adjunct Meds
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Used for muscle relaxation, analgesia,
sedation, to prevent N/V, neutralize stomach
acid. Some may also be used alone for IV
conscious sedation to induce sedation and
amnesia during a procedure.
 Advantages—provides analgesia and
amnesia; allows intubation and ease of
incision; lowers risk for aspiration
 Disadvantages—synergistic or additive
effects can increase sedation and add to risk
of respiratory complications
Postoperative Nursing Care
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PACU
– Beginning of postoperative phase
– ACP must accompany pt to PACU. Gives
report (441) and usually checks on pt
periodically. Circulator may come, too.
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After report, PACU nurse takes
responsibility.
PACU Nurse’s Responsibilities
Maintain airway
 Assess and monitor respiratory & CV
systems. LOC, fluid status, & op site
 Monitor for complications from
anesthesia and surgical procedure
 Relieve various discomforts
 Report to CRNA or surgeon for
problems
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Discharge from PACU
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Must meet Aldrete criteria (445)
 Phase I—patients are monitored closely as in
ICU until ready for phase II.
 Phase II—patients either go to ambulatory
care for d/c or inpatient care for continued
monitoring
 Phase III—patients will be discharged; either
directly from PACU or from ambulatory care.
Gerontologic Considerations
More likely to have comorbid conditions
such as CV, resp, or renal impairments
causing more risk of hypoxia and F&E
imbalances
 Hypothermia is greater risk
 Transfers are greater risk due to
musculoskeletal and skin issues
 Slower recovery from anesthesia
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Discharge from SDS (445-6)
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Pt must be able to control pain with po meds
Must void before d/c
D/C instructions include wound care, drain
mgmt, activity, diet, meds, F/U appts, what to
watch for, who to call for probs.
Make sure adult is present to take pt home
F/U care may include HH care, appts with MD
or others, and phone calls from unit.
Immediate Nursing
Responsibilities for Inpatients
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Prep of room
 When pt returns:
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Be available to assist with transfer
Assess airway and LOC
Position pt on side or in semi-Fowler’s
Connect and position all tubes, check wound
Get VS—your 1st, their last
Receive report from PACU nurse and go over
postop orders (441 chart again)
Next…..
– Assess for and do same things as PACU
nurse did on admission to PACU
– Carry out any STAT orders if not done by
PACU nurse
– Make sure pt is comfortable and in good
alignment, SR up, items WIR
– Talk to family—let them know how pt is
doing
Ongoing Responsibilities
VS acc’d to order, dept policy, or as
patient condition warrants
 Ongoing head to toe assessments with
concentration on surgical site (review
wound care), fluid balance, labs, pain
 Follow orders as written
 Control common, expected side effects
of surgery
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Common Postop Side Effects
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Pain
Weakness
Chills/decreased
circulation
Shallow breathing
Low grade temp
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Nausea
Thirst
Anorexia
Gas/decreased BS
Urinary retention
Orthostatic BP
Commonly Given Postop
Medications
Narcotics—PCA, IVP, IM, po
 Non-opioids—IVP, po
 Antibiotics—IVPB, po
 Antiemetics—IVP, rectal
 Antipruritics—IVP (epidural SE)
 H2 receptor antagonists
 May or may not give all home meds
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Preventing Complications: Why
Does the Nurse Do These?
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TCDB, IS?
Aseptic wound care?
Splinting incision?
Progressive ambulation, AEEs, TEDs?
Diet progression?
Fluid management—po and parenteral?
Promote elimination?
Balance activity and rest periods?
Emotional support—effect of dx and px?
Education?
Assessing for Complications—
How does the Nurse Know?
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Hemorrhage—internal vs. external
Fever
Wound infection
Atelectasis/PN
Persistent N/V
DVT
Fluid imbalance
Paralytic ileus
Sepsis
If Complications Arise, What
Does the Nurse Do?
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Hemorrhage
Fever
Wound Infection
Atelectasis/PN
Persistent N/V
VTE
Fluid Imbalance
Paralytic Ileus
Sepsis
Discharge Instructions