Unit 2 test Nursing Interventions

What are the 3 phases of operative nursing

preoperative

intraoperative

postoperative

what is the perioperative phase

begins when the decision to proceed with surgical intervention is made and ends with the transfer of the patient onto the operating room (OR) bed

what is the intraoperative phase

begins when the patient is transferred onto the OR bed and ends with admission to the PACU (post anesthesia care unit)

what us post operative phase

begins with the admission of the patient to the PACU and eds with a follow up evaluation in the clinical setting or home

what are the classifications of surgery

facilitating a diagnosis, a cure, or repair

reconstructive cosmetic or palliative (for pain)

rehabilitative

based upon the degree of urgency involved: emergent, urgent, required, elective, and optional

what are examples of diagnostic surgical classification

biopsy, exploratory laparotomy, or laparoscopy

What are examples of surgical procedures as a cure?

excision of a tumor or an inflamed appendix

What are examples of surgical procedures as a repair

multiple wound repair)

what are examples reconstructive or cosmetic

mammoplasty or a facelift

What is palliative surgery?

to relieve pain or correct a problem—such as debulking a tumor to achieve comfort, or removal of a dysfunctional gallbladder

what is rehabilitative

total joint replacement surgery to correct crippling pain or progression of degenerative osteoarthritis)

what is emergent surgery

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

what is urgent surgery

Patient requires prompt attention

Within 24-30

Closed fractures
Infected wound exploration/irrigation

what is required surgery

Patient needs to have surgery

Plan within a few weeks or months

Prostatic hyperplasia
Thyroid disorders
Cataracts

what is elective surgery

Elective—Patient should have surgery

Failure to have surgery not catastrophic

Repair of scars
Simple hernia
Vaginal repair

what is optional surgery

Decision rests with patient

personal preference

cosmetic surgery

What is pre admission testing(PAT)?

helps reduce cost and hospital stay

intitaties the nursing assessment process

admission data: demographics, health history, other information pertinent to the surgical procedure, consent forms, diagnostic and lab tests

Verifies completion of preoperative diagnostic testing according to patient's needs

Begins discharge planning by assessing patient's need for postoperative transportation and care

teaches what to expect day of surgery and answer questions patinet has

responsible for communicating information related to the surgical procedure and the effect that the surgical procedure and anesthetic may have on the patient's health status, functional status, and family dynamics (Malley, Kenner, Kim, et al., 2015).

**what are the three parts of the Prep phase

pre admission testing

admission to surgical center

into the preopphase

***what happens during pre-admission testing

Performs initial preoperative assessment

2.Initiates education appropriate to patient's needs

3.Involves family in interview

4.Verifies completion of preoperative diagnostic testing according to patient's needs

5.Confirms understanding of surgeon-specific preoperative prescribed therapies (e.g., bowel preparation, preoperative shower)

6.Discusses and reviews advance directive document

7.Begins discharge planning by assessing patient's need for postoperative transportation and care

what happens during admission to surgical center

Completes preoperative assessment

2.Assesses for risks for postoperative complications

3.Reports unexpected findings or any deviations from normal

4.Verifies that operative consent has been signed

5.Coordinates patient education and plan of care with nursing staff and other health team members

6.Reinforces previous education

7.Explains phases in perioperative period and expectations

8.Answers patient's and family's questions

what happens in the preoperative area

Identifies patient

2.Assesses patient's physical and emotional status, baseline pain, and nutritional status

3.Reviews medical record

4.Verifies surgical site and that it has been marked per institutional policy

5.Establishes IV line

6.Administers medications if prescribed

7.Takes measures to ensure patient's comfort

8.Provides psychological support

9.Communicates patient and family's needs to other appropriate members of the health care team

what is included in a preoperative assessment

Health history and physical exam

Medications and allergies

Nutritional, fluid status

Dentition

Drug or alcohol use

Respiratory and cardiovascular status

Hepatic, renal function

what is also included in a preop assessment

Endocrine function

Immune function

Previous medication use

Psychosocial factors

Spiritual, cultural beliefs

What is important about nutrition and fluid prior in a preop assessment

fasting helps prevent risk of aspiration

fasting can cause increase stress, loss of glycogen stores and sacrifice lean muscle which can lead to dehydration

signs of dehydrations: Low blood pressure and labs with fluid and electrolyte balance

What are the nutrients important for wound healing

protein for collagen

arginine

carbs and fats for energy

Vit C, B, A K

magnieus, cooper, zinc

What is important about dentition prior in a preop assessment

decayed teeth or dental prostheses may become dislodged during intubation and occlude the airway.

This is especially important for older patients as well as those who may not have regular dental care.

The condition of the mouth is also important because any bodily infection, even in the mouth, can be a source of postoperative infection.

What is important about drug and alcohol use prior in a preop assessment

Excessive alcohol consumption can cause arrhythmias, infections, and withdrawal.

the use of illicit drugs and alcohol may impede the effectiveness of some medications. intoxicated people are susceptible to injury, surgery is postponed if possible.

In an emergency, to prevent vomiting and potential aspiration, a nasogastric tube is inserted before general anesthesia is given.

The person with a history of alcohol abuse often suffers from malnutrition and other systemic problems or metabolic imbalances that increase surgical risk.

. Such questions should include asking whether the patient has had two drinks per day or more on a regular basis in the 2 weeks prior to surgery

What is important about respiratory status use prior in a preop assessment

education about breathing excercise and incentive spirometer

Patients who smoke are more likely to experience poor wound healing, a higher incidence of SSI, and complications that include VTE and pneumonia.

advocate for smoking cessation

Patients undergoing elective cases may have their surgery delayed or cancelled due to the potential complications associated with smoking such as respiratory infection

What is important about cardiovascular status use prior in a preop assessment

ensuring that the cardiovascular system can support the oxygen, fluid, and nutritional needs of the perioperative period.

Patients are assessed for cardiac comorbidities including congestive heart failure, shortness of breath upon movement, and arrhythmias


Preoperatively, patients may receive a chest x-ray and electrocardiogram (ECG) to rule out any undiagnosed cardiac condition.

Before surgery, the patient's baseline vital signs and blood pressure are taken.

What is important about hepatic and renal function use prior in a preop assessment

The liver, lungs, and kidneys are the routes for elimination of drugs and toxins.

Disorders of the liver may substantially affect how anesthetic agents are metabolized.

Acute liver disease is associated with high surgical mortality; preoperative improvement in liver function is a goal.

The kidneys are involved in excreting anesthetic medications and their metabolites; therefore, surgery is contraindicated if a patient has acute nephritis, acute renal insufficiency with oliguria or anuria, or other acute renal problems

what is important about endocrine function

Dysfunction of the endocrine system is associated with overproduction or underproduction of a hormone or hormones.

Patients who have received corticosteroids are at risk for adrenal insufficiency. The use of corticosteroids for any purpose during the preceding year must be reported to the anesthesiologist or CRNA and surgeon.

Patients with uncontrolled thyroid disorders are at risk for thyrotoxicosis (with hyperthyroid disorders) or respiratory failure (with hypothyroid disorders).

The patient with diabetes who is undergoing surgery is at risk for both hypoglycemia and hyperglycemia.

Hypoglycemia may develop during anesthesia or postoperatively from inadequate carbohydrates or excessive administration of insulin

Hyperglycemia, which can increase the risk of SSI, may result from the stress of surgery, which can trigger increased levels of catecholamine. Other risks are acidosis and glucosuria.

***diabetes, corticosteroids, thyroid disorders

what is important about immune function for preop

determine the presence of infection or allergies.

WBC and urinalysis

Surgery may be postponed in the presence of infection or elevated temperature

It is important to identify and document any sensitivity to medications, solutions, adhesives, and past adverse reactions

what are medications that potentially affect surgical experience

Corticosteroids

Diuretics

Phenothiazines

Tranquilizers

Insulin

Antibiotics

Anticoagulants

Anticonvulsant medications

Thyroid hormone

Opioids

Over-the-counter and herbals

how do corticosteroids interact with aesthetics

Cardiovascular collapse can occur if discontinued suddenly.

Therefore, a bolus of corticosteroids may be administered IV immediately before and after surgery.

can effect renal activity

how do diruetics interact with aesthetics

can cause fluid/electrolyte imbalance

e.g Hydrochlorothiazide
During anesthesia, may cause excessive respiratory depression resulting from an associated electrolyte imbalance.

how do Phenothiazines interact with aesthetics

e.g Chlorpromazine hydrochloride
May increase the hypotensive action of anesthetics.

how does Tranquilizers interact with aesthetics

e.g Diazepam May cause anxiety, tension, and even seizures if withdrawn suddenly.

how does insulin interact with anesthetics

Interaction between anesthetics and insulin must be considered when a patient with diabetes is undergoing surgery. IV insulin may need to be given to keep the blood glucose within the normal range.

how does anticoagulants interact with anesthetics

e.g warfin

Can increase the risk of bleeding during the intraoperative and postoperative periods; should be discontinued in anticipation of elective surgery.

The surgeon will determine how long before the elective surgery the patient should stop taking an anticoagulant, depending on the type of planned procedure and the medical condition of the patient.

how does Anticonvulsant medications
interact with anesthetics

e.g Carbamazepine

IV administration of medication may be needed to keep the patient seizure-free in the intraoperative and postoperative periods.

how does thyroid medication interact with anesthetics

e.g Levothyroxine sodium

IV administration may be needed during the postoperative period to maintain thyroid levels.

how does opioids interact anesthetics

e.g Morphine sulfate

Long-term use of opioids for chronic pain (≥6 mo) in the preoperative period may alter the patient's response to analgesic agents.

immunosuppression is common with what

corticosteroid therapy

organ transplantation

radiation therapy

chemotherapy

disorders affecting the immune system, such as acquired immunodeficiency syndrome and leukemia.

The mildest symptoms or slightest temperature elevation must be investigated.

can herbs effect surgical risk

yes, review table 14-4 on page 407 prior to rest to get an understanding of some herbs and supplements

what are the gerontological considerations

Cardiac reserves are lower

decreased or slow circulation in response to anesthesia


Renal and hepatic functions are depressed

Gastrointestinal activity is likely to be reduced

Respiratory compromise

skin assessment

Decreased subcutaneous fat; more susceptible tot emperature changes

May need more time and multiple education formats to understand and retain what is communicated

decline in cognition and increased confusion when stressed

what to consider with patients with obesity

Preoperative assessment of the patient with obesity should pay careful attention to pulmonary, cardiovascular, psychological, and integumentary systems

The increase in adipose tissue can result in difficult intravenous (IV) access and delayed wound healing at the incision site

associated with increased SSIs and joint replacement failure. Patients with a body mass index (BMI) of greater than 45 are at a significantly increased risk for total joint replacement failure and postoperative infection

tends to have shallow respirations when supine, increasing the risk of hypoventilation and postoperative pulmonary complications.

obstructive sleep apnea (OSA)

risks can dramatically reduce intubation and postoperative complications

what to consider with disabilities

the need for appropriate assistive devices, modifications in preoperative education, and additional assistance with and attention to positioning or transferring. Assistive devices include hearing aids, eyeglasses, braces, prostheses, and other devices.

surgical team should incorporate a plan of care that ensures safe patient movement and handling.

Patients with respiratory problems related to a disability (e.g., multiple sclerosis, muscular dystrophy) may experience difficulties unless the problems are made known to the anesthesiologist or CRNA and adjustments are made

what to consider patients undergoing ambulatory surgery

includes outpatient, same-day, or short-stay surgery not requiring admission for an overnight hospital stay but may entail observation in a hospital setting for 23 hours or less

, the nurse must quickly and comprehensively assess and anticipate the needs of the patient and at the same time begin planning for discharge and follow-up home care.

Other preoperative education content should also be verified and reinforced as needed.

The nurse should ensure that any plans for follow-up home care or new assistive devices are in place if needed.

what to consider patients undergoing emergency surgery

unplanned and occur with little time for preparation of the patient or the perioperative team.

It is important for the nurse to communicate with the patient and team members as calmly and effectively as possible in these situations.

For the patient who is unconscious, essential information, such as pertinent past medical history and allergies, need to be obtained from a family member, if one is available.

what is important about informed consent

Should be in writing before non emergent surgery

Legal mandate

Surgeon must explain the procedure, benefits, risks,complications, etc.

Nurse clarifies information and witnesses signature

Consent is valid ONLY when signed before administering psychoactive premedication

Consent accompanies patient to OR

what is important patient education

Deep breathing, coughing, incentive spirometry

Mobility, active body movement: imporve circulaition, prevent venous stasis, and promote resp. function

Pain management

Cognitive coping strategies: guided imagery, distraction, optimistic self-reciation, music therapy, aroma therapy, reiki

Instruction for patients undergoing ambulatory surgery

what are immediate preoperative nursing interventions

Patient changes into gown, hair covered, mouth inspected, jewelry removed, valuables stored in a secure place

Administering preanesthetic medication

Maintaining preoperative record

Transporting patient to presurgical area

Attending to family needs

what are general preoperative nursing interventions

Providing psychosocial interventions
o Reducing anxiety, decreasing fear
o Respecting cultural, spiritual, religious beliefs

Maintaining patient safety

Managing nutrition, fluids

Preparing bowel

Preparing skin

how are fluids and nutrition managed preoperatively

fast 8 hrs after fatty foods, 6 hrs after milk

healthier patients can have clear liquids up to 2 hrs

carb loading: A carbohydrate-rich drink has been used as a safe fasting process before surgery. It has been reported that these solutions do not pose a risk for aspiration and decrease insulin resistance when the duration of gastric emptying and the amount of liquid intake are controlled enhanced recovery after surgery protocol has demonstrated positive outcomes including decreased LOS, decreased incidence of PONV, and decreased pain

how to prep the bowel preoperatively

a cleansing enema or laxative may be prescribed the evening before surgery and may be repeated the morning of surgery.

The goals of this preparation are to allow satisfactory visualization of the surgical site and to prevent trauma to the intestine or contamination of the peritoneum by fecal material.

Unless the condition of the patient presents some contraindication, the toilet or bedside commode, rather than the bedpan, is used for evacuating the enema if the patient is hospitalized during this time.

In addition, antibiotics may be prescribed to reduce intestinal flora.

how to prep the skin preoperatively

goal of preoperative skin preparation is to decrease bacteria without injuring the skin.

If the surgery is not performed as an emergency, most health care facilities and ambulatory surgical centers have implemented preoperative antiseptic skin cleansing protocols.

At a minimum, preoperative bathing should consist of a full-body wash using antimicrobial soap the night before the planned surgery

Additional body cleansing with chlorhexidine wipes may occur in the preoperative area via the nurse or by the patient under the direction of the nurse.

Surgical site hair removal should occur in the preoperative area. Electric clippers, not skin razors, are the preferred method for hair removal

what are expected outcomes for preop

Relief of anxiety

Decreased fear

Understanding of the surgical intervention

No evidence of preoperative complications

CHAPTER 15 intraoperative

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who is apart of the surgical team

Patient

Anesthesiologist (physician) or certified registered nurse anesthetist (CRNA)

Surgeon

Nurses

Surgical technicians

Registered nurse first assistants (RNFAs) or certified surgical technologists (assistants)

what are the surgical team roles

circulation nurse

scrub

surgeon

registered nurse first assistant

anesthesiologist, anesthetist

note: role of nurse as patient advocate

what does the circulating nurse do

coordinates the care of the patient in the OR.

Care provided by the circulating nurse includes planning for and assisting with patient positioning, preparing the site for surgery, managing surgical specimens, anticipating the needs of the surgical team, documenting intraoperative events, and updating the plan of care.

what does the scrub do

provide sterile instruments and supplies to the surgeon during the produced by anticipation surgical needs at the surgical case processes

what are intraoperative complications

Anesthesia awareness

Nausea, vomiting

Anaphylaxis

Hypoxia, respiratory complications

Hypothermia

Malignant hyperthermia

Infection

what are adverse effects of surgery and anesthesia

Allergic reactions, drug toxicity or reactions

Cardiac dysrhythmias

CNS changes, oversedation, under sedation

Trauma: laryngeal, oral, nerve, skin, including burns

Hypotension

Thrombosis

what are gerontologic considerations

Older adult patients are at higher risk for complications from anesthesia and surgery compared to younger adult patients due to several factors

:o Age-related cardiovascular and pulmonary changes

o Decreased tissue elasticity (lung and cardiovascular systems) and reduced lean tissue mass

o Decreases the rate at which the liver can inactivate many anesthetic agents

o Decreased kidney function slows the elimination of waste
products and anesthetic agents

o Impaired ability to increase metabolic rate and impaired thermoregulatory mechanisms

What is malignant hyperthermia?

A side effect of general anesthesia - tachycardia, hypertension, acid-base and electrolyte abnormalities, muscle rigidity, hyperthermia

what are the measures for prevention of infection

Surgical environment o Unrestricted zone: street clothes allowed
o Semi restricted zone: scrub clothes and caps

o Restricted zone: scrub clothes, shoe covers,caps, and masks

Surgical asepsis

Environmental controls

what are the basic guidelines for surgical asepsis (10)

All materials in contact with the surgical wound or used within the sterile field must be sterile

Gowns considered sterile in front from chest to level of sterile field, sleeves from 2 inches above elbow to cuff

Sterile drapes are used to create a sterile field. Only top of draped tables are considered sterile

Items dispensed by methods to preserve sterility

Movements of surgical team are from sterile to sterile, from non sterile to unsterile only
Movement at least 1-foot distance from sterile field must be maintained

When sterile barrier is breached, area is considered contaminated

Every sterile field is constantly maintained,monitored Items of doubtful sterility considered unsterile

Sterile fields prepared as close to time of use

The routine administration of hyperoxia (high levels of oxygen) is not recommended to reduce surgical site infections

what are the different delivery systems for anesthetic agents

general

inhalation

intravenous

regional

epidural

spinal

what are nursing intervention for intraop

Reducing anxiety

Reducing latex exposure

Preventing perioperative positioning injury

Protecting patient from injury

Serving as patient advocate

Monitoring, managing potential complic

what are positioning factors to consider

Patient should be as comfortable as possible

Operative field must be adequately exposed

Position must not obstruct/compress respirations,vascular supply, or nerves

Extra safety precautions for older adults, patients who are thin or obese, and anyone with a physical deformity

Light restraint before induction in case of excitement

how to protect the patient from injurt

Patient identification

Correct informed consent

Verification of records of health history, exam

Results of diagnostic tests

Allergies (include latex allergy)

Monitoring, modifying physical environment

Safety measures(grounding of equipment, restraints,not leaving a sedated patient)

Verification, accessibility of blood

CHAPTER 16 PostOP

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what is Postanesthesia care

PACU

phase 1 and 2

what is PACU

post anesthesia care unit

patient is still under or recovering from anesthesia

easy access to experienced, highly skilled nurses, anesthesia providers, surgeons, advanced hemodynamic

pulmonary monitoring and support, special equipment, and medications.

what happens in phase 1 of post anesthesia care

immediate recover

intensive nursing care

patient transitions to an inpatient nursing unit or phase 2

what is phase 2 of PACU

prepared for transfer to an inpatient nursing unit, an extended care setting, or discharge

recliners rather than stretches or beds are standard

stay in PACU until they meet predetermined discharge criteria

what is the nursing management in the PACU

provide care for patient until patience has recovered from effects of anesthesia

o Return to cognitive baseline

o Clear airway

o Controlled nausea and vomiting

o Stable vital signs

Vital to perform frequent skilled assessment ofpatient
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what are the responbilites of the PACU nurse

Review pertinent information, baseline assessment upon admission to unit

Assess airway, level of consciousness, cardiac,respiratory, wound, and pain

Check drainage tubes, monitoring lines, IV fluids,and medications

Assess vital signs at the time of arrival to PACU andrepeated per institution protocol

Administration of postoperative analgesia

Transfer report to another unit or discharge patient to home, continuing or transitional care, refer toCharts 16-1 and 16-3

How does the nurse assess the patinet in the PACU

assess airway, Level of consciousness, cardiac, respiratory, wound, and pain

additional/; peripheral pulses, hemodynamics, surgical drain replacements


aldrete score(7-10)

nurse performs and documents a baseline assessment, checks all drainage tubes, and verifies that monitoring lines are connected and functioning.

Iv fluids and medications

review patinet history and vital signs

why does the nurse maintian the patients airway

goal: maintain ventilation to prevent hypoxemia and hypercapnia

how does the nurse maintain the patient's airway

give O2

assess respiratory rate, depth, eas of respiration, O2 sat, breath sounds, and ventilation

endotracheal tube that cannot be removed until gagging reflex occurs

open mouth with padded tongue depressor in patients with clenched teeth

suction vomit or mucus, turn patinet to side is vommit occurs

elevate HOB to 15-30 degrees unless contraindicated

what is hypopharyngeal obstruction

Patients who have experienced prolonged anesthesia usually are unconscious, with all muscles relaxed.

This relaxation extends to the muscles of the pharynx.

When the patient lies on the back, the lower jaw and the tongue fall backward and the air passages become obstructed

What is occulusion?

blockage

what are signs of occulsion

noisy and irregular respirations

decreased oxygen saturation scores

, within minutes, a blue, dusky color (cyanosis) of the skin

how does nurse properly check patient is breathing

movement of the thorax and the diaphragm does not necessarily indicate that the patient is breathing,

the nurse needs to place the palm of the hand at the patient's nose and mouth to feel the exhaled breath

how does the nurse maintain cardiovascular stability

assess

level of consciousness; vital signs; cardiac rhythm; skin temperature, color, and moisture; and urine output and the patency of all IV lines

additional: venous pressure, pulmonary artery pressure, pulmonary artery wedge pressure, and cardiac output for critically ill, risky procedures, or comorbidity.

what are cardiovascular complications

hypotension and shock, hemorrhage, hypertension, and arrhythmias

what can cause hypotension

blood loss(> 500ml) hypoventilation, position changes, pooling of blood in the extremities, or side effects of medications and anesthetic

what are the types of shock

hypovolemic(most common and due to hemorrhage from sugrical site)

cardiogenic, neurogenic, anaphylactic, and septic.

what are the signs of hypocalmeic shock

pallor

cool, moist skin

rapid breathing

cyanosis of the lips, gums, and tongue

rapid, weak, thready pulse

narrowing pulse pressure

low blood pressure

concentrated urine

what is the primary intervention for shock

avoided largely by the timely administration of IV fluids, blood, blood products, and medications that elevate blood pressure

volume replacement, with an infusion of lactated Ringer solution, 0.9% sodium chloride solution, colloids, or blood component therapy

If fluid administration fails to reverse hypovolemic shock, then various cardiac, vasodilator, and corticosteroid medications may be prescribed to improve cardiac function and reduce peripheral vascular resistance.

what are signs of hemmorhage

hypotension; rapid, thready pulse; disorientation; restlessness; oliguria; and cold, pale skin.

The early phase of shock will manifest in feelings of apprehension, decreased cardiac output, and vascular resistance. Breathing becomes labored, and "air hunger" will be exhibited;

the patient will feel cold (hypothermia) and may experience tinnitus. Laboratory values may show a sharp drop in hemoglobin and hematocrit levels.

If shock symptoms are left untreated, the patient will continually grow weaker but can remain conscious until near death

how to relive pain and anxiety

Assess patient comfort

Control of environment: quiet, low lights, noise level

Administer analgesics as indicated; usually short-acting opioids IV

Family visit, dealing with family anxiety

Nonpharmacologic, emotional, and psychological support

How to control nausea and vomiting

Intervene at first indication of nausea


Medications

Assessment of postoperative nausea, vomiting risk,prophylactic treatment

what are non pharmacological option for Nausea/ vomiting

Aromatherapy inhalers with ginger, lavender, spearmint, and peppermint are a complementary, homeopathic, and a nonpharmacologic option

what are gerontological consideration

Decreased physiologic reserve

Monitor carefully,frequently

Increased confusion

Dosage

Hydration

Thermoregulation

Increased likelihood of postoperative confusion,delirium

Hypoxia, hypotension,hypoglycemia

Reorient as needed

Pain

what is outpatient surgery/direct discharge

Discharge planning, discharge assessment

Provide written, verbal instructions regarding follow-up care,complications, wound care, activity, medications, diet

Give prescriptions, contact information

o Discuss actions to take if complications occur

Give instructions to patient, responsible adult who will accompany patient Patients are not to drive home or be discharged to home alone
o Sedation, anesthesia may cloud memory, judgment, affect decision-making ability

what is the nursing management of the hospitalized postoperative patient

Asess:

respiratory

pain

mental status/LOC

general discomofort

what is the purpose of postoperative dressing

Provide healing environment

Absorb drainage

Splint or immobilize

Protect

Promote homeostasis

Promote patient's physical and mental comfort