Transcript perioperative client

Perioperative
client
By I.KORDA
Perioperative period
Preoperative
Intraoperative
Postoperative
Care of preoperative client
 Education
 Preoperative
procedures
Purposes of surgery
 Diagnostic
 Curative
 Restorative
 Palliative
 Cosmetic
Urgency
Elective
Urgent
Emergent
Emergent—Patient requires immediate
attention
Disorder may be life-threatening
 Without
delay
Severe
bleeding
Bladder or intestinal obstruction
Fractured skull
Gunshot or stab wounds
Extensive burns
Urgent—Patient requires prompt
attention

Within 24–30 h
 Acute
gallbladder infection
 Kidney or ureteral stones
Required—Patient needs to have
surgery

Plan within a few weeks or months
 Prostatic
hyperplasia without bladder
obstruction
 Thyroid disorders
 Cataracts
Elective—Patient should have
surgery

Failure to have surgery not catastrophic
 Repair
of scars
 Simple hernia
 Vaginal repair
Optional—Decision rests with
patient

Personal preference
 Cosmetic
surgery
Degree of risk
 Minor
 Major
Category by location
Abdominal
Intracranial
Heart etc.
Surgical settings
Ambulatory care centers and physician
offices are the usual settings for minor
surgical procedures.
 Outpatient surgery areas (one-day surgery
centers or free-standing ambulatory
clinics) provide the client and physician
with alternative services for urgent and
elective surgeries.

Perioperative Management
of Care
 Surgeon
responsibilities
Determine
the need for the surgical
intervention.
Determine the surgical setting in
collaboration with the client.
Order diagnostic tests.
Obtain
client’s consent for the
surgical procedure.
Teach the client about the
outcomes and risks of the
procedure.
Explain and document evidence
that the client understands the
nature of the surgical procedure,
the risk factors, and expected
outcomes of the surgery.
Criteria for Valid Informed
Consent






Voluntary Consent
Explanation of procedure and its risks
Description of benefits and alternatives
An offer to answer questions about procedure
Instructions that the patient may withdraw
consent
A statement informing the patient if the protocol
differs from customary procedure
• Invasive procedures, such as a surgical
incision, a biopsy, a cystoscopy, or
paracentesis
• Procedures requiring sedation and/or
anesthesia
• A nonsurgical procedure, such as an
arteriography, that carries more than slight
risk to the patient
• Procedures involving radiation
 Anesthesia
Obtain
provider responsibilities
informed consent for anesthesia.
Perform a preanesthesia evaluation that
includes a thorough history.
Select anesthetic agents.
Teach the client regarding the
anesthetic medications, their side
effects, and risk factors.
Perform
intubation (the insertion of
an endotracheal tube into the
bronchus through the nose or mouth
to ensure an airway)
and extubation (the removal of an
endotracheal tube).
 Nurse
responsibilities
Schedule
the diagnostic tests.
Verify that all the necessary
documents are on the client’s medical
record.
Report abnormal diagnostic results to
the surgeon.
Prepare and teach the client.
Collaborative management
History
 Physical assessment
 Psychosocial assessment
 Laboratory assessment
 Radiographic assessment
 Other diagnostic assessment

Collaborative Management
Assessment

History and data collection
 Age
 Drugs
and substance use
 Medical history, including cardiac and
pulmonary histories
 Previous surgery and anesthesia
 Blood donations
 Discharge planning
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
Cardiovascular system
 Respiratory system
 Renal/urinary system
 Neurologic system
 Musculoskeletal system
 Nutritional status
 Psychosocial assessment
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Laboratory Assessment
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
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Deficient Knowledge
Interventions
Preoperative teaching
 Informed consent

 The
surgeon is responsible for obtaining
signed consent before sedation is given
and surgery is performed.
 The nurse’s role is to clarify facts
presented by the physician and dispel
myths that the client or family may have
about surgery.
Implementing Dietary
Restrictions
Client is given nothing by mouth (NPO) for
6 to 8 hours before surgery.
 NPO status decreases the risk for
aspiration.
 Failure to adhere can result in cancellation
of surgery or increase the risk for
aspiration during or after surgery.
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Administering Regularly
Scheduled Medications
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Consult the medical physician and
anesthesia provider for instructions about
drugs, such as those taken for diabetes,
cardiac disease, glaucoma, regularly
scheduled anticonvulsants,
antihypertensives, anticoagulants,
antidepressants, or corticosteroids.
Intestinal Preparation
Bowel or intestinal preparations are
performed to prevent injury to the colon
and to reduce the number of intestinal
bacteria.
 Enema or laxative may be ordered by the
physician.

Skin Preparation
The skin is the body’s first line of defense
against infection; a break in the barrier
increases the risk for infection.
 Shower using antiseptic solution.
 Shaving as a procedure before surgery is
viewed as controversial.

Preparing the Client
Possible placement of tubes, drains, and
vascular access devices
 Teaching about postoperative procedures
and exercises:

 Breathing
exercises, incentive spirometry,
coughing and splinting
(Continued)
Preparing the Client (Continued)
Leg
procedures and exercises,
antiembolism stockings and elastic
wraps, early ambulation, and rangeof-motion exercises
Anxiety Interventions
Preoperative teaching
 Encouraging communication
 Promoting rest
 Using distraction
 Teaching family and significant others
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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.
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(Continued)
Preoperative Chart Review
(Continued)
Ensure results of all laboratory and
diagnostic tests are on the chart.
 Document and report any abnormal
results.
 Report special needs and concerns.
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Preop Client Prep
Client should remove most clothing and
wear a hospital gown.
 Valuables should remain with family
member or be locked up.
 Tape rings in place if they can’t be
removed.
 Remove all pierced jewelry.

(Continued)
Preop Client Prep (Continued)
Client wears an identification band.
 Dentures, prosthetic devices, hearing aids,
contact lenses, fingernail polish, and
artificial nails must be removed.

Preoperative Medication
Reduce anxiety.
 Promote relaxation.
 Reduce pharyngeal secretions.
 Prevent laryngospasm.
 Inhibit gastric secretion.
 Decrease amount of anesthetic needed for
induction and maintenance of anesthesia.

Interventions for
Intraoperative
Clients
Members of the Surgical
Team
Surgeon
 Surgical assistant
 Anesthesiologist
 Certified registered nurse anesthetist
 Holding area nurse
 Circulating nurse
 Scrub nurse
 Surgical technologist
 Operating room technician

Environment of the Operating
Room
Preparation of the surgical suite and team
safety
 Layout
 Health and hygiene of the surgical team
 Surgical attire
 Surgical scrub

Anesthesia
Induced state of partial or total loss of
sensation, occurring with or without loss of
consciousness
 Used to block nerve impulse transmission,
suppress reflexes, promote muscle
relaxation, and, in some instances,
achieve a controlled level of
unconsciousness

General Anesthesia
Reversible loss of consciousness is
induced by inhibiting neuronal impulses in
several areas of the central nervous
system.
 State can be achieved by a single agent or
a combination of agents.
 Central nervous system is depressed,
resulting in analgesia, amnesia, and
unconsciousness, with loss of muscle tone
and reflexes.

Stages of General
Anesthesia
Stage 1: analgesia
 Stage 2: excitement
 Stage 3: operative
 Stage 4: danger
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Administration of General
Anesthesia
Inhalation: intake and excretion of
anesthetic gas or vapor to the lungs
through a mask
 Intravenous injection: barbiturates,
ketamine, and propofol through the blood
 Adjuncts to general anesthetic agents:
hypnotics, opioid analgesics,
neuromuscular blocking agents

Balanced Anesthesia
Combination of intravenous drugs and
inhalation agents used to obtain specific
effects
 Combination used to provide hypnosis,
amnesia, analgesia, muscle relaxation,
and reduced reflexes with minimal
disturbance of physiologic function

(Continued)
Balanced Anesthesia
(Continued)

Example: thiopental for induction, nitrous
oxide for amnesia, morphine for analgesia,
and pancuronium for muscle relaxation
Complications from General
Anesthesia
Malignant hyperthermia: possible
treatment with dantrolene
 Overdose
 Unrecognized hypoventilation
 Complications of specific anesthetic
agents
 Complications of intubation

Local or Regional Anesthesia
Sensory nerve impulse transmission from a
specific body area or region is briefly
disrupted.
 Motor function may be affected.
 Client remains conscious and able to follow
instructions.
 Gag and cough reflexes remain intact.
 Sedatives, opioid analgesics, or hypnotics are
often used as supplements to reduce anxiety.

Local Anesthesia
Topical anesthesia
 Local infiltration
 Regional anesthesia

 Field
block
 Nerve block
 Spinal anesthesia
 Epidural anesthesia
Complications of Local or
Regional Anesthesia
Anaphylaxis
 Incorrect delivery technique
 Systemic absorption
 Overdosage

(Continued)
Complications of Local or
Regional Anesthesia
(Continued)

Assess for central nervous system
stimulation, central nervous system and
cardiac depression, restlessness,
excitement, incoherent speech, headache,
blurred vision, metallic taste, nausea and
vomiting, tremors, seizures, increased
pulse, respirations, and blood pressure.
Treatment of Complications
Establish an open airway.
 Give oxygen.
 Notify the surgeon.
 Fast-acting barbiturate is usual treatment.
 If toxic reaction is untreated,
unconsciousness, hypotension, apnea,
cardiac arrest, and death may result.

Conscious Sedation
IV delivery of sedative, hypnotic, and
opioid drugs reduces the level of
consciousness but allows the client to
maintain a patent airway and to respond to
verbal commands.
 Diazepam, midazolam, meperidine,
fentanyl, alfentanil, and morphine sulphate
are the most commonly used drugs.

(Continued)
Conscious Sedation (Continued)

Nursing assessment of airway, level of
consciousness, oxygen saturation,
electrocardiographic status, and vital signs
are monitored every 15 to 30 minutes.
Collaborative Management
Assessment
 Medical record review
 Allergies and previous reactions to
anesthesia or transfusions
 Autologous blood transfusion
 Laboratory and diagnostic test results
 Medical history and physical examination
findings

Risk for Perioperative
Positioning Injury
Interventions include:
 Proper body position
 Risk for pressure ulcer formation
 Prevention of obstruction of circulation,
respiration, and nerve conduction
Impaired Skin Integrity and
Impaired Tissue Integrity
Interventions include:
 Plastic adhesive drape
 Skin closures, sutures and staples,
nonabsorbable sutures
 Insertion of drains
 Application of dressing
 Transfer of client from the operating room
table to a stretcher
Potential for Hypoventilation

Continuous monitoring of:
 Breathing
 Circulation
 Cardiac
rhythms
 Blood pressure and heart rate

Continuous presence of an anesthesia
provider
Interventions for
Postoperative
Clients
PACU Recovery Room
Purpose is to provide ongoing evaluation
and stabilization of clients to anticipate,
prevent, and treat complications after
surgery.
 PACU is usually located close to the surgical
suite.
 The PACU nurse is skilled in the care of
clients with multiple medical and surgical
problems that can occur following a surgical
procedure.
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Collaborative Management
Assessment
 Physical assessment and clinical
manifestations


Assess respiration.
 Examine surgical area for bleeding
 Monitor vital signs.
 Assess for readiness to discharge once
criteria have been met.
Respiratory System
Airway assessment
 Breath sounds
 Other respiratory assessments

Cardiovascular Assessment
Vital signs
 Cardiac monitoring
 Peripheral vascular assessment

Neurologic System
Cerebral functioning
 Motor and sensory assessment important
after epidural or spinal anesthesia

 Motor
function: simple commands; client to
move extremities
 Return of sympathetic nervous system tone:
gradually elevate head and monitor for
hypotension
Fluid, Electrolyte, and AcidBase Balance
Check fluid and electrolyte balance.
 Make hydration assessment.
 Intravenous fluid intake should be
recorded.
 Assess acid-base balance.

Renal/Urinary System
The effects of drugs, anesthetic agents, or
manipulation during surgery can cause
urine retention.
 Assess for bladder distention.
 Consider other sources of output such as
sweat, vomitus, or diarrhea stools.
 Report a urine output of < 30 mL/hr.

Gastrointestinal System
Nausea and vomiting are common
reactions after surgery.
 Peristalsis may be delayed because of
long anesthesia time, the amount of bowel
handling during surgery, and opioid
analgesic use.
 Clients who have abdominal surgery often
have decreased peristalsis for at least 24
hours.

Nasogastric Tube Drainage

Tube may be inserted during surgery to
decompress and drain the stomach, to
promote gastrointestinal rest, to allow the
lower gastrointestinal tract to heal, to
provide an enteral feeding route, to
monitor any gastric bleeding, and to
prevent intestinal obstruction.
(Continued)
Nasogastric Tube Drainage
(Continued)
Assess drained material every 8 hours.
 Do not move or irrigate the tube after
gastric surgery without an order from the
surgeon.

Skin Assessment
Normal wound healing
 Ineffective wound healing: can be seen most
often between the 5th and 10th days after
surgery

 Dehiscence:
a partial or complete separation of
the outer wound layers, sometimes described as
a “splitting open of the wound.”
(Continued)
Skin Assessment (Continued)
 Evisceration:
a total separation of all wound
layers and protrusion of internal organs
through the open wound.

Dressings and drains, including casts and
plastic bandages, must be assessed for
bleeding or other drainage on admission to
the PACU and hourly thereafter.
Discomfort/Pain Assessment
Client almost always has pain or
discomfort after surgery.
 Pain assessment is started by the
postanesthesia care unit nurse.
 Pain usually reaches its peak the second
day after surgery, when the client is more
awake, more active, and the anesthetic
agents and drugs given during surgery
have been excreted.

Impaired Gas Exchange
Interventions include:
 Airway maintenance
 Positioning the client in a side-lying
position or turning his or her head to the
side to prevent aspiration
 Encouraging breathing exercises
 Encouraging mobilization as soon as
possible to help remove secretions and
promote lung expansion
Impaired Skin Integrity
Interventions include:
 Nursing assessment of the surgical area
 Dressings: first dressing change usually
performed by surgeon
 Drains: provide an exit route for air, blood,
and bile as well as help prevent deep
infections and abscess formation during
healing
(Continued)
Impaired Skin Integrity
(Continued)
Drug therapy including antibiotics and
irrigations are used to treat wound
infection.
 Surgical management is required for
wound opening.

Acute Pain
Interventions include:
 Drug therapy
 Complementary and alternative therapies
such as:
 Positioning
 Massage
 Relaxation
and diversion techniques
Potential for Hypoxemia
Interventions include:
 Maintenance of airway patency and
breathing pattern
 Prevention of hypothermia
 Maintenance of oxygen therapy as
prescribed
The classic signs of shock are:
• Pallor
• Cool, moist skin
• Rapid breathing
• Cyanosis of the lips, gums, and tongue
• Rapid, weak, thready pulse
• Decreasing pulse pressure
• Low blood pressure and concentrated
urine
Patient’s readiness for discharge
from the PACU
• Stable vital signs
• Orientation to person, place, events, and time
• Uncompromised pulmonary function
• Pulse oximetry readings indicating adequate
blood oxygen saturation
• Urine output at least 30 mL/h
• Nausea and vomiting absent or under control
• Minimal pain
Health Teaching
Prevention of infection
 Dressing care
 Nutrition
 Pain medication management
 Progressive increase in activity level
 Use of proper body mechanics

The end