Transcript Serum or capillary glucose tests morning of surgery

Peri-Operative
Created by: Cindy Lutkenhaus, MSN,RNC-OB
CHAPTERS 18, 19, 20
Fall 2015
Pre-operative

Interview pt- psychosocial and physical assessment-

Risk Factors

Health History

Current Rx meds, OTC, and herbal supplements, ALLERGIES
Pre-op teachingTCDB
SCD or VTE preventative
What to expect in OR to reduce anxiety
Placement of IV
NPO status
Common pre-op meds p. 329
Pre-operative

Informed consent
 Nurse
 SCIP
can witness signature only. Informed of risks/benefits by Doctor
Measures (surgical care improvement protocol)
 Hair
clipped, not shaved.
 Antibiotic
 Urinary
catheter removed within 24 hrs of surgery
 Prevent
 Give
30-60 minutes prior to surgery, DC’d 24 hrs after operation
VTE
beta-blockers if currently on this med
Pre-operative

Common Fears
 Death/
permanent disability
Postponement
 Alteration
in body image/Mutilation
 Pain
 Anesthesia
 Disruption
of life
Nursing Assessment

Cardiovascular system
•
Report
 Any
cardiac problems so they can be monitored during the
intraoperative period
 Use
of cardiac drugs
 Presence
of pacemaker/ICD
•
12-lead electrocardiogram (ECG)
•
Coagulation studies
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Nursing Assessment

Respiratory system
•
Inquire about recent airway infections
 Procedure
could be cancelled because of increased risk of
laryngo/bronchospasm or decreased SaO2
•
History of dyspnea, coughing, hemoptysis, COPD or asthma
 High
•
risk for atelectasis and hypoxemia
Smokers should be encouraged to quit 6 weeks before procedure
 Decreases
 Greater
•
risk of complications
years and number of packs = greater risk
Sleep apnea, obesity, and airway deformities affect respiratory
function
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Nursing Assessment

Nervous system
•
Evaluation of neurologic functioning
Vision
or hearing loss can influence results of
informed consent
Cognitive
deficits can affect informed
consent and cause adverse outcomes
during and after surgery
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Nursing Assessment

Genitourinary system
•
History of urinary or renal diseases
•
Renal dysfunction contributes to
 Fluid
and electrolyte imbalances
 Increased
 Impaired
 Altered
risk of infection
wound healing
response to drugs and their elimination
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Nursing Assessment

Genitourinary system
•
Renal function tests
•
Note problems voiding, and inform
operative team
•
Assess women for possibility of
pregnancy
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Nursing Assessment


Hepatic system
•
Liver detoxifies many anesthetics and adjunctive drugs
•
Hepatic dysfunction may increase risk of postoperative complications
Integumentary system
•
History of skin and musculoskeletal problems
•
History of pressure ulcers
 Extra
padding during procedure
 Affects
•
postoperative healing
Body art, tattoos, piercings
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Nursing Assessment

Musculoskeletal system
•
Identify joints affected with arthritis
•
Mobility restrictions may affect positioning and ambulation
•
Bring mobility aids to surgery
•
Report problems affecting neck or lumbar spine to ACP
(anesthesia care provider)
Can
affect airway management and anesthesia delivery
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Nursing Assessment

Endocrine system
•
Patients with diabetes mellitus are especially at risk for:
 Hypo/hyperglycemia
 Ketosis
 Cardiovascular
 Delayed
alterations
wound healing
 Infection

Serum or capillary glucose tests morning of surgery (baseline)

Clarify with physician or ACP regarding insulin dose
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Nursing Assessment

Endocrine system
•
Patients with thyroid dysfunction
 Hyper-/hypothyroidism
metabolic rate
 Verify
•
poses surgical risks because of altered
with ACP about giving thyroid medications
Patients with Addison’s disease
 Abruptly
stopping replacement corticosteroids could cause
Addisonian crisis
 Stress
of surgery may require increased dose of IV corticosteroids
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Nursing Assessment

Immune system
•
Patients with history of compromised immune system or use of
immunosuppressive drugs can have
 Delayed
wound healing
 Increased

risk for infection
Fluid and electrolyte status- Usually NPO
•
Vomiting, diarrhea, or difficulty swallowing can cause imbalances
•
Identify drugs that alter F and E status
 Diuretics
•
Evaluate serum electrolyte levels
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Nursing Assessment

Nutritional status
•
Obesity (Person of Size)
 Stresses
cardiac and pulmonary systems
 Increased
risk of wound dehiscence, infection, and incisional hernia
 Slower
recovery from anesthesia
 Slower
wound healing
•
Provide extra padding to underweight patients to prevent pressure
ulcers
•
May be protein and vitamin deficient
•
Identify dietary habits that may affect recovery (e.g., caffeine)
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Nursing Management

Preoperative teaching
•
Patient right to know what to expect and how to participate
 Increases
 Reduces
•
patient satisfaction
fear, anxiety, stress, pain, and vomiting
Limited time available
 Address
needs of highest priority
 Include
information focused on safety
 Provide
written material
 Anxiety
and fear can hinder learning
 Give
priority to patient’s concerns
 Must
be documented and reported to postoperative nurses
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Nursing Management

Preoperative teaching
•
Teach deep breathing, coughing, and early ambulation as appropriate
•
Inform if tubes, drains, monitoring devices, or special equipment will be used
postoperatively
•
Provide surgery-specific information
•
Basic information before arrival
 Time
and place
 Fluid
and food restrictions
 Need
for enema
 Need
for shower
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Inc.
Nursing Management

Legal preparation
•
All required forms are signed and in chart
Informed
Blood
consent
transfusions
Advance
Power
directives
of attorney
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Nursing Management

Consent for surgery
•
Informed consent must include
 Adequate
disclosure
 Understanding
 Voluntarily

and comprehension
given consent
Surgeon responsible for obtaining consent
•
Nurse may obtain and witness signature
•
Verify patient has understanding
•
Permission may be withdrawn at any time
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Nursing Management

Consent for surgery
•

Medical emergency may override need for consent
Legally appointed representative of family may consent
if patient is
•
Minor
•
Unconscious
•
Mentally incompetent
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Nursing Management


Void before surgery
•
Prevents involuntary elimination under anesthesia or during early
postoperative recovery
•
Before medication administration
Preoperative medication
•
Benzodiazepines
•
Anticholinergics
•
Opioids
•
Antiemetics
•
Antibiotics
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Nursing Management

Transportation to the OR
•
Via stretcher or wheelchair
•
Communication “handoff”
 Situation
 Background
 Assessment
 Recommendation
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Physical Environment

Holding area

National Patient Safety Goals (NPSGs) require a preprocedure process, including:
Verification
Required
of relevant documentation
blood products and equipment
Diagnostic
and radiology test
Procedure
site marked
Surgical Team

Perioperative nurse
 Is
a registered nurse (RN)
 Prepares
 Serves
room with team
as patient advocate throughout surgical experience
 Maintains

patient safety, privacy, dignity, confidentiality
Circulating nurse

Not scrubbed, gowned, or gloved

Remains in unsterile field

Documents (charts)
Surgical Team

Scrub nurse (LVN, CST)
 Follows
designated hand scrub procedure
 Gowned
and gloved in sterile attire
 Remains
in sterile field
 Passes
instruments and implements other technical
functions during procedure
Nursing Management

Room preparation
 Surgical
attire worn by all persons entering OR suite
 Electrical
function
 Aseptic
and mechanical equipment checked for proper
technique practiced when placing instruments
Counts
Functions
of team members delineated
Nursing Management

Transferring patient
 Patient
transported into OR after preparation
 Sufficient
number of staff to lift, guide, and prevent
patient falls, as well as injury to staff
Persons
 Caution
 Wheels
of size
with monitor leads, IVs, and catheters
locked
Nursing Management

Basic aseptic technique
 Center of sterile field is site of surgical incision
 Only sterilized items in sterile field


Protective equipment
 Face shields, caps, gloves, aprons, and eyewear
Assisting anesthesia care provider
 Know location of emergency equipment and drugs in the OR
 Circulating nurse may place monitoring devices on patient
 Remain at patient’s side to ensure safety
Nursing Management

Safety considerations
 Fire
 Smoke
particles
 Universal
 Surgical
protocol
time-out
To prevent wrong site, wrong surgery, wrong patient.
TIME OUT prior to each surgery/procedure - all staff must
agree. ID pt, procedure, surgical site, informed consent
Nursing Management

Positioning of patient
 Correct
skeletal alignment
 Prevent
pressure on nerves, skin, bony prominences, or eyes
 Provide
for adequate thoracic excursion
 Accessibility
of operative site
 Administration
 Maintenance
and monitoring of anesthetic agents
of airway
 Prevent
occlusion of arteries and veins
 Provide
modesty in exposure
 Recognize
and respect needs such as pain or deformities
Nursing Management


Preventing hypothermia

Closely monitor temperature

Apply warming blankets

Bair Hugger blankets or gowns

Increased risk of infection, impaired wound healing
Preparing surgical site

Scrub or clean around the surgical site with antimicrobial agents
 Use
a circular motion from clean to dirty area
 Allow

to fully dry
Hair may be removed with clippers prior to scrub
Nursing Management

After surgery
 Perioperative
nursing data set (PNDS) reflects
standards of nursing care in any perioperative setting
Care
plans in the OR
 ACP
and perioperative team member take patient to
PACU and give report
 Handoff
procedure
Gerontologic Considerations

Anesthetic drugs should be carefully titrated

Assess for poor communication

Risk from tape, electrodes, and warming/cooling
blankets

Osteoporosis and osteoarthritis

Perioperative hypothermia
Catastrophic Events in the OR

Anaphylactic reactions
 Manifestation
may be masked by anesthesia
 Meds
 Latex
 Vigilance
and rapid intervention are essential
 Symptoms
include hypotension, tachycardia, bronchospasm,
pulmonary edema
Catastrophic Events in the OR

Malignant hyperthermia

Rare inherited metabolic disorder

Hyperthermia with rigidity of skeletal muscles

Often occurs with exposure to succinylcholine, especially in conjunction
with inhalation agents

Usually occurs under general anesthesia but may also occur in recovery

Treatment dantrolene, cold IV fluids and irrigation
Catastrophic Events in the OR

Malignant hyperthermia
 Tachycardia
 Tachypnea
 Hypercarbia
 Ventricular
dysrhythmias
 Rise
in body temperature NOT an early
 Can
result in cardiac arrest and death
sign
Post Anesthesia Care (PACU)
Post-operative

Anesthesia provider and circulator SBAR to PACU nurse

PACU nurse assessment important because detects and manages
post-op complications

Emergence Delirium (Neuro comp, hypoxia, anesthesia, pain or ET
tube)

Examples of post-op complications:
 ??
 Maintain
safety is still a large concern
 Managing
 Rewarm
pt
pain
Postoperative Period

Begins immediately after surgery
•
PACU is located adjacent to OR
 Minimizes
 Provides

transport
immediate access to anesthesia and OR personnel
Nursing care focus
•
Protecting patient
•
Preventing complications post- surgical procedure
PACU Admission Report
 Intraoperative
management
 Anesthetic
medications used
 Other medications
received
 Blood loss
 Fluid replacement
 Urine output
 Intraoperative
course
 Unexpected
anesthetic events or
reactions
 Unexpected surgical
events
 Vital signs and
trends
 Results of
intraoperative
laboratory tests
Postoperative Assessment
Circulation
 Airway
 Patency
 Artificial
 ECG
airway
Breathing
 RR
and quality
 Breath sounds
 Supplemental
oxygen
 Continuous pulse
oximetry
monitoring
 Vital signs
 Peripheral pulses
 Capillary refill
 Skin color and
temperature
Postoperative Assessment
 Neurologic
Glasgow
Coma Scale
 Genitourinary
 LOC/
 Intake
 Orientation
 Output
 Sensory
and
motor status
 Pupil
size and
reaction
fluids)
(IV
(urine
and NG)
 Estimated
blood loss
(EBL)
Postoperative Assessment
 Gastrointestinal
 Bowel
sounds
 NG—Verify
placement to
suction or
clamped
 Nausea
 Surgical
site
Dressing
CDI
Pain
Incisional
Postoperative
Complications
Respiratory
•
Airway obstruction
•
Hypoxemia
•
Atelectasis
•
Aspiration
•
Bronchospasm
•
Hypoventilation
Nursing Interventions to
Prevent Respiratory
Complications
 Oxygen
therapy
 Cough and deep breathing
 Change patient position every 1–2 hours
 Early mobilization
 Adequate hydration
 Parenteral
 Chest
or oral
physical therapy
 Pain management
Splinting With a Pillow or Blanket
Postoperative Complications
Cardiovascular




Hypotension, Syncope
Hypertension
Dysrhythmias
VTE
 Frequent
vital signs monitoring
 Continuous ECG monitoring
 Adequate fluid replacement
 Assess surgical site for bleeding
Postoperative
Complications
Neurologic/Psychologic
 Emergence
 Delayed
delirium
emergence
 Anxiety
 Postoperative
 Alcohol
cognitive dysfunction (POCD)
withdrawal delirium
Nursing Interventions to Prevent
Neuropsychologic Complications

Monitor oxygen levels
with pulse oximetry

Fluid and electrolyte
balance

Oxygen therapy

Adequate nutrition

Pain management

Sleep

Reversal agents (Phase I)


Assess for anxiety and
depression
Proper bowel and
bladder functioning

Monitor mobility status
and activity status for
safety

Alcohol protocols
Nursing Interventions to
Prevent Pain and Discomfort
Analgesics
• Epidural catheter
• Patient-controlled analgesia
(PCA)
•
Nursing Interventions to Prevent
Hypothermia and Fever
•
Passive warming
•
Active warming
•
Oxygen therapy
•
Opioids
•
Meticulous asepsis
•
Coughing/deep breathing
Postoperative Complications
Gastrointestinal

Nausea/vomiting

Abdominal distension

Postoperative ileus

Delayed gastric emptying

Hiccups
Nursing Interventions to Prevent
GI Complications

Nausea/vomiting
 Antiemetics/prokinetics
 NG
suction as ordered

Adequate hydration

Assess bowel function
 Presence
 Is

of bowel sounds/flatulence
the patient hungry?
Early mobilization
Postoperative Complications
Urinary
•
Retention
•
Oliguria
•
Infection (CAUTI)

Monitor urine output

Adequate hydration

Remove urinary catheter when no longer indicated

Normal positioning for elimination

Bladder scan/straight catheter per orders
Postoperative Complications
Surgical Site Infection


Surgical site/wounds
• Surgical site infection (SSI)
• Hematoma
• Dehiscence
Assess the wound
 Note drainage color, consistency, and amount
 Assess effect of position changes on wound/drain tube
drainage
 Signs/symptoms (S/S) of infection
 Ordered prophylactic antibiotics
 Maintain glycemic control
Used
Modified Aldrete Scoring
System
to assess transition from PACU to discharge
 Discontinuation
of anesthesia to return of protective reflexes
and motor function
A
score of 9 or 10 indicates readiness for transfer or
discharge to the next phase of recovery
Modified Aldrete Scoring System
DISCHARGE CRITERIA
Score
Consciousness
Fully awake
2
Arousable to voice
1
Unresponsive
0
Activity: Able to move voluntarily or on command
Four extremities
2
Two extremities
1
No extremities
0
Respiration
Able to take deep breath and cough
2
Dypsnea/shallow breathing
1
Apnea
0
Modified Aldrete Scoring System
DISCHARGE CRITERIA
Score
Oxygen Saturation
Saturation maintains > 92% on room air
2
Needs oxygen to maintain saturation > 92%
1
Saturation > 90% even with supplemental oxygen
0
Circulation
BP within + 20 mm Hg of preoperative level
2
BP within + 20-50 mm Hg of preoperative level
1
BP within + 50 mm Hg of preoperative level
0
PACU
Discharge Criteria

Patent airway

Patient awake

Hemodynamic stability
•
BP and HR, sinus rhythm

No respiratory depression

Oxygen saturation > 90%

Pain management

Condition of surgical site (no excessive bleeding)

N/V, Bowel Sounds
Discharge Criteria from PACU

Hemodynamic stability

Pain and comfort management

Condition of surgical site and dressings/drainage
tubes

Fluid/hydration status (voided if appropriate)

Mobility status—can ambulate if not contraindicated

Emotional status

Patient safety needs

Significant other interactions
Gerontologic Considerations
Postoperative Patient
 Decreased
 Altered
 Drug
vascular function
toxicity
 Mental
 Pain
respiratory function
status changes
control