Transcript Perioperative and Postoperative Nursingx

Perioperative and
Postoperative
Nursing
NURS 230/Spring 2014
History of Surgical Nursing
• Association of periOperative Registered
Nurses (AORN)
– Established in 1956
– Focus on clinical practice, professional practice,
administrative practice, patient outcomes, and
quality improvement
• Ambulatory surgery
– Hospital-based or freestanding
– Many laparoscopic surgeries, such as
gallbladder removal (cholecystectomy)
Classification of Surgery
• Seriousness
– Major or minor
• Urgency
– Elective, urgent, emergency
• Purpose
– Diagnostic, ablative, palliative,
reconstructive/restorative, procurement for
transplant, constructive, or cosmetic
• Moribound: at the point of death
• American Society of PeriAnesthesia Nurses
(ASPAN)
Nursing Process:
Preoperative Surgical Phase
Assessment
Diagnosis
Planning
Implementation
Evaluation
Assessment/Pre-op phase
• Nursing history
• Medical history
– Past illnesses, surgeries, and reasons for surgery
• Risk factors
– Age, nutrition, obesity, sleep apnea,
immunocompetence, fluid and electrolyte
imbalance, and pregnancy
Risk Factors
Age
Nutrition
Obesity
Sleep apnea
Immunocompetence
Fluid and
electrolyte
imbalance
Pregnancy
Assessment (cont’d)
• Perceptions and knowledge
• Medication history
– Prescription
– Over the counter
– Herbs
– Street drugs
• Allergies
– Drugs, latex, food, and contact
Assessment/Pre-op phase
• Smoking
– Cigarettes or packs per day
• Alcohol ingestion and substance use/abuse
– Use per day or week
• Support sources
– Family, friends, home environment
Assessment/ Pre-op Phase
•
•
•
•
•
•
Occupation
Preoperative pain assessment
Emotional health
Self-concept
Body image
Culture
Physical Examination
•
•
•
•
•
•
•
•
General survey
Head and neck
Integument
Thorax and lungs
Heart and vascular system
Abdomen
Neurological
Diagnostic screenings
Nursing Diagnosis and Planning
Nausea
Ineffective airway
clearance
Anxiety
Delayed surgical
recovery
Fear
Risk for deficient
fluid volume
Deficient knowledge
(specify)
Impaired physical
mobility
Risk for infection
Acute pain
Risk for perioperative positioning
injury
Implementation
• Informed consent: legal issue
• Preoperative teaching:
– Reasons for preoperative Instructions and
exercises; time of surgery
– Postoperative unit and location of family during
surgery and recovery; anticipated postoperative
monitoring and therapies
– Surgical procedures and postoperative treatment;
postoperative activity resumption
– Patient verbalizes pain relief measures.
– Patient expresses feelings regarding surgery.
Acute Care
• Physical preparation
– Maintaining normal fluid and electrolyte
balance
– Reducing risk of surgical site infection
– Preventing bladder and bowel incontinence
– Promoting rest and comfort
Acute Care (cont’d)
• Preparation on day of surgery
– Hygiene
– Hair and cosmetics
– Removal of prostheses
– Safeguarding valuables
– Preparing the bowel and bladder
– Vital signs
– Documentation
– Other procedures
– Administering preoperative medications
– Eliminating wrong site and wrong procedure
surgery
Eliminating wrong site and wrong procedure
surgery
The three principles of The Joint Commission (TJC) protocol to avoid
wrong site and wrong procedure surgery include the following:
(1)Preoperative verification that ensures that all relevant
documents (e.g., consent forms, allergies, medical history,
physical assessment findings) and results of laboratory tests and
diagnostic studies are available before the start of the procedure,
and that the type of surgery scheduled is consistent with the
patient’s expectations
(2) Marking of the operative site with indelible ink to mark left and
right distinction, multiple structures (e.g., fingers), and levels of the
spine
(3) “Time out” just before the start of the procedure for final
verification of correct patient, procedure, and site, and any implants –
make sure you watch the you tube videos at the end of this ppt
Preoperative Evaluation
• Evaluate whether the patient’s
expectations were met with respect to
surgical preparation.
• During evaluation, include a discussion of
any misunderstandings, so patient concerns
can be clarified.
• When patients have expectations about
pain control, this is a good time to reinforce
how pain will be managed after surgery.
Day of Surgery
•
•
•
•
•
•
Physical preparation
Hygiene
Vital signs
Documentation
Preoperative meds
Surgical time out
Intraoperative Surgical Phase
• Transport to the operating room
• Preoperative (holding) area
– IV placement
– Anesthesia assessment
• Admission to the operating room
• Nursing process
– Assessment
– Nursing diagnosis
– Planning
Intraoperative Implementation
• Physical preparation
– Monitoring




– Graded compression stockings
Latex sensitivity/allergy
Introduction of anesthesia
Positioning the patient for surgery
Documentation of intraoperative care
Introduction of Anesthesia
• General
– Loss of all sensation and consciousness
– Induction, maintenance, and emergence
• Regional
– Loss of sensation in one area of the body
• Local
– Loss of sensation at a site
• Conscious sedation/moderate sedation
– Used for procedures that do not require
complete anesthesia
Intraoperative Evaluation
• The circulating nurse conducts an ongoing
evaluation to ensure that interventions
such as patient position are implemented
correctly during the intraoperative phase of
surgery.
– Circulating nurse
– Scrub nurse
• Evaluate the patient’s ongoing clinical
status. Continuously monitor vital signs and
intake and output.
Quick Quiz!
1. When conducting preoperative patient and
family teaching, you demonstrate proper use
of the incentive spirometer. You know that the
patient understands the need for this
intervention when the patient states, “I use
this device to
A. Help my cough reflex.”
B. Expand my lungs after surgery.”
C. Increase my lung capacity.”
D. Drain excess fluid from my lungs.”
Postoperative Surgical Phase
• Immediate postoperative recovery (phase
1)
– Arrival
– Hand-off: OR to PACU
– Systems assessment
– Discharge and hand-off: PACU to Acute Care
Postoperative Surgical Phase
• Recovery in ambulatory surgery (phase 2)
– Postanesthesia recovery score for ambulatory
patients (PARSAP)
– Observation
– Discharge
• Postoperative convalescence
Postoperative Convalescence: Assessment
• Airway and respiration
• Circulation
• Temperature control
– Malignant hyperthermia (covered at the end of
this PPT)
• Fluid and electrolyte balance
• Neurological functions
Postoperative Assessment
•
•
•
•
Skin integrity and condition of the wound
Metabolism
Genitourinary function
Gastrointestinal function
– Paralytic ileus
• Comfort
Postoperative Implementation
• Maintaining respiratory function
– Start pulmonary intervention early.
• Preventing circulatory complications
– Foster circulation.
• Achieving rest and comfort
– Administer pain medications.
Postoperative Nursing Diagnosis and Planning
• Determine status of preoperative diagnosis.
• Revise or resolve preoperative diagnosis;
identify relevant new diagnoses.
• Goals and outcomes:
– Patient’s incision remains closed and intact.
– Patient’s incision remains free of infectious
drainage.
– Patient remains afebrile.
• Setting priorities
• Teamwork and collaboration
Acute Postop Care: Implementation
Maintaining
Respiratory Function
Patency, rate, rhythm, symmetry, breath
sounds, color of mucous membranes
Preventing Circulatory Heart rate, rhythm, BP, capillary refill, nail beds,
Complications
peripheral pulses
Achieving Rest and
Comfort
Enhance the efficacy of pain control, minimize
side effects of each modality
Temperature
Regulation
Malignant hyperthermia
Maintaining
LOC, gag and pupil reflexes
Neurological Function
continued…
Postop Care: Implementation
Maintaining Fluid and
Electrolyte Balance
IV, I&O, compare baseline lab
values
Promoting Normal Bowel
Elimination and Adequate
Nutrition
Anesthesia slows motility.
Promoting Urinary
Elimination
Urinary function returns in 6 to 8
hours.
Promoting Wound Healing
Check skin for rashes, petechiae,
abrasions, or burns; wound for
drainage.
Maintaining/Enhancing SelfConcept
Observe patients for behaviors
reflecting alterations in selfconcept.
Quick Quiz!
2. Postoperatively, the nurse instructs the
patient to perform leg exercises every hour
to
A. Maintain muscle tone.
B. Assess range of motion.
C. Exercise fatigued muscles.
D. Increase venous return.
Implementation: Restorative and Continuing
Care
• Preparation for discharge
– Continue wound care.
– Follow diet or activity restrictions.
– Continue medication therapy.
– Watch for complications.
• Some patients need home care after
discharge; others require discharge to a
skilled nursing facility.
Evaluation
• Examples of evaluation questions:
– “Are you satisfied with the way we are
managing your pain?”
– “Do you feel you have learned enough to be
able to follow your diet at home?”
– “Are you having any ongoing issues, questions,
or concerns that we can address for you at this
time?”
• Evaluate whether the patient and the
family have learned self-care measures.
Final Checklist….KNOW THIS!
• http://www.youtube.com/watch?v=IAvwxKJVI
DE
Final Time-Out
• http://www.youtube.com/watch?v=RJzdBF7I6w&feature=related
Postoperative Pulmonary
Complications
• 5- 10% all surgical patients
• 9- 40% after abdominal surgery
•
Wong et al. Factors associated with postoper. pulmonary complications in patients with severe COPD. Anesthesia
Analgesia 1995;80:276-284.
The most important and morbid
postoperative pulmonary complications
1. Atelectasis
2. Pneumonia
3. Respiratory failure
4. Exacerbation of underlying chronic lung disease
Breathing and Coughing
Exercises
• The sitting position gives
the best lung expansion
for coughing and deep
breathing exercises
• Inhale through the nose
and exhale through the
mouth with pursed lips
• Hold breath for three
seconds and cough
• Cough and deep breathe
q 2 h while awake
DVT/VTE Risk Factors:
•
•
•
•
•
•
•
•
•
•
•
Age 40-60 years
Age > 60 (count as 2 factors)
History of DVT or PE (count as 5
factors)
Malignancy
Obesity (>120 % of BW)
Previous or present immobilization
(>72hrs)
Anticipated immobilization/bed
confinement >72 hrs
Major Surgery
Paralysis
Trauma
Indwelling central venous catheter
•
•
•
•
•
•
•
•
•
•
•
Severe COPD
Pregnancy, or post partum < 1 month
(tendency to bleed)
Inflammatory bowel disease
Severe sepsis
Hypercoagulable state (clot to easily)
Nephrotic Syndrome (kidney failure)
Current or previous estrogen use
w/in last 5 days
Leg ulcers, edema, or stasis
(varicose veins)
History of MI
History of CHF (congestive heart
failure)
History of Stroke
6 W’s of Post-Operative Fever
• Wind: the pulmonary system is the primary source of
fever in the first 48 hours.
• Wound: there might be an infection at the surgical site.
• Water: check intravenous access site for signs of
phlebitis.
• Walk: deep venous thrombosis can develop due to pelvic
pooling or restricted mobility related to pain and fatigue.
• Whiz: a urinary tract infection is possible if urinary
catheterization was required.
• Wonder drugs: drug fevers (anesthesia, heparin,
antibiotics, anticonvulsants).
BIG,
,
Bad
Ugly
Malignant Hyperthermia
• Rare genetic disorder manifests after treatment of with anesthetic
agents: succinylcholine and halothane
• Onset is usually in 1 hour of the administration of anesthesia, rarely
delayed up to 10 hours
• ½ of cases are inherited in as Autosomal Dominant
• In the presence of anesthetic agents uncontrolled Ca ++ efflux from
the SR  tetany,↑ and heat production
Malignant Hyperthermia
• Early clinical findings in malignant hyperthermia include
muscle rigidity (especially masseter (jaw) stiffness),
tachycardia, increased CO2 production, and skin cyanosis with
mottling (purple and blue)
• Marked hyperthermia (up to 45ºC [113ºF]) occurs minutes to
hours later; core body temperature tends to rise 1ºC every 5 to
60 minutes.
• Hypotension
Management:
Malignant hyperthermia
• Dantrolene administration is the mainstay of treatment of malignant
hyperthermia, and should be initiated as soon as the diagnosis is
suspected.
• Since the introduction of dantrolene, the mortality of this syndrome has
fallen from close to 70 percent to less than 10 percent.
• Dantrolene is a nonspecific muscle relaxant that acts by blocking the
release of calcium from the SR  decreases the myoplasmic
concentration of free calcium and diminishes the myocyte
hypermetabolism that causes clinical symptoms.
• Most effective when given early in the illness (ie, before hyperthermia
occurs), when maximal calcium can be retained within the muscle
• A 2 mg/kg IV bolus is given and should be repeated every 5 minutes until
symptoms abate up to a maximum dose of 10 mg/kg.
• This may be repeated every 10 to 15 hours. After an initial response, the
drug should be continued orally at a dose of 4 to 8 mg/kg per day, in four
divided doses, for three days.