Transcript 05. Interventions for preoperative clients care

Interventions for
Preoperative Clients Care
Perioperative Care
Three Phases
Preoperative
 Preoperative
 Intraoperative
 Postoperative
Miss Iman Shaweesh
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PREOPERATIVE NURSING
CARE
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CONDUCT A NURSING ASSESSMENT
PROVIDE PREOPERATIVE TEACHING
PERFORM METHODS OF PHYSICAL
PREPARATION
ADMINISTER MEDICATIONS
ASSIST WITH PSYCHOSOCIAL
PREPARATION
COMPLETE THE SURGICAL CHECKLIST
SURGERY CHECKLIST
Purposes of Surgery
Diagnostic
 Curative
 Restorative
 Palliative surgery, which makes the
client more comfortable
 Cosmetic surgery, which reconstructs
the skin and underlying structures
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Collaborative Management
Assessment
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History and data collection
Age
 Drugs and substance use
 Medical history, including cardiac and
pulmonary histories
 Previous surgery and anesthesia
 Blood donations
 Discharge planning
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Physical Assessment/Clinical
Manifestations
Obtain baseline vital signs.
 Focus on problem areas identified by
the client’s history on all body
systems affected by the surgical
procedure.
 Report any abnormal assessment
findings to the surgeon and to
anesthesiology personnel.
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System Assessment
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Cardiovascular system
Respiratory system
Renal/urinary system
Neurologic system
Musculoskeletal system
Nutritional status
Psychosocial assessment
Laboratory Assessment
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Urinalysis
Blood type and crossmatch
Complete blood count or hemoglobin level and
hematocrit
Clotting studies
Electrolyte levels
Serum creatinine level
Pregnancy test
Chest x-ray examination
Electrocardiogram
Preparing the Client (Continued)
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Leg procedures and exercises,
antiembolism stockings and elastic
wraps, early ambulation, and range-ofmotion exercises
DEEP BREATHING, COUGHING, LEG
EXERCISES
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Deep breathing is a form of controlled ventilation that opens
and fills small air passages in the lungs to prevent atelectasis
and pneumonia.
Coughing is a natural method of clearing secretions from the
airways.
Leg exercises help promote circulation and reduce the risk of
forming a thrombus in the veins.
Antiembolism stockings help prevent thrombi and emboli by
compressing superficial veins and capillaries redirecting blood
to larger and deeper veins, where it flows more effectively
toward the heart.
DEEP BREATHING & COUGHING
Pre-Operative Education
Diaphragmatic Breathing Exercises
Pre-Operative Education
Splinting Abdomen while Coughing
Spirometry
Use of preoperative spirometry to predicted PPCs
Jacob 1997
Bando 1997
Kocabas 1996
Kroenke 1993
Kispert 1992
Swensson 1991
Fogh 1987
Appleberg 1974
Stein 1970
Collin 1968
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Adapt from Smetana GW,et al. New Engl J Med 1999;340:937-944.
Preoperative Care of Pulmonary
Patients: Example
Male 60 yrs.
 Dx: NSCLC stage Ib , RUL
 Underlying COPD
 Assessment
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Not urgent surgery, high benefit
 Risk ; elderly, COPD
 History / Physical examination
 Laboratory
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Spirometry of the patient
PreRX(%)
Post –
RX(%)
FEV1/FV
C (%)
55
60
FEV1 (L)
1.31(48
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1.39(53)
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FVC (L)
2.40(66
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2.50(69)
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FEF25- 75%
0.43(15
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0.6(22)
22
(L/min)
%CH
G
Further evaluation
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PPO-FEV1
RUL = 24.7%
LL = 55%
RLL= 20.3%
RUL : RLL= 0.55: 0.45
Preoperative Care of Pulmonary Patients
Many factors related to PPCs
 Working as a team plays major roles
 Assessment of the risks ,do appropriated
testing and modifying are the keys of
preoperative caring
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Recommendation for
preoperative CXR
Age > 50 years
 Known pre-existing cardiopulmonary
diseases
 S/S like hoods of cardiopulmonary disease
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Smetana GW, et al Med Clin N Am 2003
PFTs and PPCs
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Case-control study, elective abdominal
surgery:
CXR highly associated with PPCs (OR 5.8)
 Abnormal PE associated with PPCs
 Whereas PFTs were not predictive
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Lawrence VA, et al. Chest 1996;110:744-50.
PFT Diagram in Preoperative Evaluation
FEV1 >2 L
MVV >50%
DLCO >60%
PFT(FEV1,MVV,DLCO)
Cleared for any resection
PPO-FEV1 >1.3
Cleared for any resection
FEV1 > 2 L
MVV<50%
DLCO <60%
FEV1 <2 L
High risk consider exercise test
Perfusion Scanning PPO-FEV1
PPO-FEV1 <0.8
Consider “Lesser” resection
Non surgical therapy
PPO-FEV1
>0.8, <1.3
High risk consider exercise test
Preoperative PFTs : Summary
Thoracic surgery
 Upper abdominal surgery with
respiratory symptoms remain
unexplained after careful evaluation
 Routine PFTs should not ordered solely
without clinical assessment
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Risk indices for preoperative assessment
Pneumonia
Risk
(total point)
Predicted
Prob.
pneumonia
(%)
Respiratory
Failure
(total point)
Predicted
Prob.
Res. failure
(%)
1
0-15
0.2
0-10
0.5
2
16-25
1.2
11-19
2.2
3
26-40
4.0
20-27
5.0
4
41-55
9.4
28-40
11.6
5
>55
15.4
>40
30.5
Risk
class
Arozullah AM,et al. Med Clin N Am 2003
Preoperative smoking cessation and PPCs
% Complication
60
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20
10
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Stop >2 mth
Stop<2 mth
Stop>6 mth
Never smoke
Prospective study 200 patients, CABG
Warner MA,et al. Mayo Clin Proc 1989
Preoperative smoking cessation and PPCs
% Complication
60
50
40
30
20
10
0
Current <2wks Recent2-4wks
Exsmoke
Never smoke
Retrospective study 288 patients, pulmonary surgery
Nakagawa M, et al Chest 2001;120:705-10
Examples of external pneumatic
compression devices used to promote
venous return and prevent deep vein
thrombosis (DVT)
Kendall SCD machine, sleeves, and
TED stockings.
Venodyne pneumatic compression system
Flowtron DVT calf garments
Anxiety Interventions
Preoperative teaching
Encouraging communication
Promoting rest
Using distraction
Teaching family and significant others
Preoperative Chart Review
Ensure all documentation, preoperative
procedures, and orders are complete.
Check the surgical consent form and
others for completeness.
Document allergies
Document height and weight.