MEDSURGE LESSON 1 FLASHCARDS

Perioperative Nursing

Nursing specialty that works with patients having operative and other invasive procedures

Perioperative Nurse

• Surgical or operating room nurse

• Specialized nurse caring for patients before, during and after surgery

3 Phases of Perioperative Nursing

1.) Preoperative Phase

2.) Intraoperative Phase

3.) Postoperative Phase

Preoperative Phase

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

Intraoperative Phase

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

Postoperative Phase

Begins with the admission of the patient to the PACU and ends with a follow-up evaluation in the clinical setting or home

Classification of Surgery

• Diagnostic

• Curative

• Reparative

• Reconstructive or Cosmetic

• Palliative

Diagnostic

• Mainly, the surgical intervention is done to know more what disease the patient may have

• Ex: Biopsy or exploratory laparotomy

Curative

• Aiming to cure patient with surgery

• Ex: Excision of a tumor

Reparative

• Ex: Multiple wound repair

Reconstructive or Cosmetic

Ex: Facelift

Palliative

• To relieve pain or correct a problem

• Ex: Debulking – removing a part of Stage IV tumor (cannot be cured anymore) that already stuck itself to the spine

Classification of Surgery Based on Urgency

• Emergent

• Urgent

• Required

• Elective

• Optional

Emergent

• Immediate attention needed; disorder may be life threatening

• It’s indication for surgery is without delay

• Ex: Severe bleeding & Cannot urinate or defacate = organs becoming bloated,

Urgent

• Requires prompt attention

• It’s indication for surgery is within 24-30

  hours

• Ex: Acute gallbladder infection & Very painful to the patient (If not addressed immediately)

Required

• Needs to have surgery

• It’s indication for surgery is planned within a few weeks or months

• Ex: Prostatic hyperplasia without bladder obstruction; thyroid disorders; cataracts

Elective

• Should have the surgery

• It’s indication for surgery is when failure to have surgery is not catastrophic

• Ex: Repair of scars; simple hernia; vaginal repair

Optional

• Decision rests with the patient

• It’s indication for surgery is for personal

  preference

• Ex: Cosmetic surgery

Classification of Surgery Based on Degree of Risk

• Major

• Minor

Major Degree of Risk

• Usually extensive and warrant an overnight or extended stay in the hospital

• Include extensive work such as entering a body cavity, removing an organ or altering the body’s anatomy

• Usually require anesthesia or respiratory assistance and sometimes even both

Minor Degree of Risk

• Generally superficial and do not require penetration of a body cavity

• Do not involve assisted breathing or anethesia and are usually performed by a single doctor

As of today, Nursing Students are required to assist in

In 6 Major Surgeries

Minor and Major Categories are based on

PhilHealth’s Related Value Unit (RVU) where each procedure has a relative value unit (points)

80 Points and Above

Considered Major

Informed Consent

• The patient’s autonomous decision about whether to undergo a surgical procedure

• LEGAL mandate (no surgical procedure will proceed if there’s no informed consent)

• Should be voluntary

• Necessary before non emergent surgery

• Protect the patient from unsanctioned surgery

• Protect the surgeon from claims of an unauthorized operation

Informed Consent is necessary in the following circumstances:

• Invasive procedures

• Procedures requiring sedation and/or anesthesia

• A non-surgical procedure that carries slight risk to the patient (e.g. arteography)

• Procedures involving radiation (since it causes complications and side effects in the future

How to know if Informed Consent is Valid?

1.) Voluntary Consent

2.) Incompetent Patient

3.) Informed Subject

4.) Patient Able to Comprehend

Voluntary Consent

• Freely given, without coercion

• Must be at least 18 years of age unless emancipated minor - e.g. wa pa kaabot 18 and way maka take care niya, has own work, lives by himself, etc. (needs to be proven)

Incompetent Patient

• Individual who is NOT autonomous and cannot give or withhold consent.

• E.g. cognitively impaire, mentally ill, or neurologically incapacitated

Informed Subject

• Should contain explanation of procedure & its risk

• Description of benefits and alternatives

• An offer to answer questions (time to explain to the patient should not be the time na nagdali ang patient)

• Instructions that the patient may withdraw consent

• Information about protocols that may be different from customary procedure (if slight changes dapat informed gihapon ang patient)

Patient Able to Comprehend

• E.g use of interpreter and alternative formats of communication

• Expert in sign language if the patient is deaf or mute (As much as possible if a relative of the patient or S/O knows how to do sign language, it is best if that person should NOT be utilized as an interpreter. It should be independent from the hospital.)

Role of Nurse on Informed Consent

1.) Ask the Patient to Sign the Consent Form

2.) Witness the Signature

3.) Clarifies Information Provided

4.) Notifies the Physician if Patient asks for Additional Information

5.) Ascertains that the Consent Form has been Signed before Administering Psychoactive Premedication

Ask the Patient to Sign the Consent Form

• Dili na trabaho sa nurse to explain the benefits or risk but we get the patient to sign when he or she has fully understood all of the things in regards to the surgery.

Witness the Signature

• But we can witness the signature. Most consent has a witness signature. If walay relatives ang patient, the nurse can be a witness.

Clarifies Information Provided

• If there are slight questions the patient might ask, ikaw ang dapat mo hatag sa clarification. The nurse must have an idea on what surgery the patient will go through.

Notifies the Physician if Patient asks for Additional Information

• If the patient asks detailed question about the procedure, it is our responsibility to notify the physician for additional information

Ascertains that the Consent Form has been Signed before Administering Psychoactive Premedication

• Make sure consent has been signed already before giving psychoactive premedication

Role of Surgeon on Informed Consent

1.) Responsible to provide a clear and simple explanation of what the surgery will entail prior to the patient giving consent

2.) Inform about the following:

• Benefits

• Alternativeness (if naay lain noninvasive procedures that the patient can undergo)

• Possible risks

• Complications

• Disfigurement

• Disability

• Removal of body parts

• What to expect in the early and late postoperative periods

Considerations on Informed Consent

• Surrogate

• In an Emergency

Surrogate

• Responsible family member (preferably next of kin)

• Legal guardian

In an Emergency

• Surgery is necessary as a life saving measure

• However, every effort must be made to contact the patient’s family

Quality and Safety Nursing Alert

The signed consent form is placed in a prominent place on the patient’s medical record and accompanies the patient to the OR.

Preoperative Phase

Begins when the patient decides to go on with the surgery up to the point when the patient is already transferred to the OR bed.

Preoperative Phase Goals

• The patient should be as healthy as possible

• Health history is obtained

• Physical examination is performed

Preoperative Assessment

1.) Nutritional and Fluid Status

2.) Dentition

3.) History of Drug or Alcohol Use

4.) Respiratory Status (preoperative)

5.) Respiratory Infections: postpone surgery

6.) Underlying Respiratory diseases (e.g. asthma)

7.) Other Comorbid conditions, like HIV and Parkinson’s Disease

8.) Assess if patient is a Smoker, instruct that smoking should be stopped 4-8 weeks before surgery

9.) Cardiovascular Status

10.) Hepatic and Renal Function

11.) Endocrine Function

12.) Immune Function

13.) Previous Medication Use

14.) Psychosocial Factors

15.) Spiritual and Cultural Belief

Nutritional and Fluid Status

• Identify factors that can affect the patient’s surgical course, such as obesity, weight loss, malnutrition, deficiencies in specific nutrients, metabolic abnormalities, and the effects of medications on nutrition.

• Ex. intake of a lot of antacid would actually inhibit the absorption of iron.

• Measurement of body mass index and waist circumference.

  • Normal BMI: 18.5-24.9

  • Reminder for BMI: it is calculated by weight in kg ÷ height in m

• Nutritional deficiency should be corrected (prior to scheduling of any operative procedure)

• Any identified fluid and electrolyte imbalances should be corrected prior to surgery

Dentition

• Assess for dental caries and dentures

  • May become dislodged during intubation and occlude the airway.

• Especially important for older patients as well as those who may not have regular dental care.

• Infection in the mouth can be a source of postoperative infection.

History of Drug or Alcohol Use

• Moderate amounts of alcohol prior to surgery can weaken a patient’s immune system and increase the likelihood of developing postoperative complications (Rubinsky, Bishop, Maynard, et al., 2013).\

• Use of elicit drugs and alcohol may impede the effectiveness of some medications

• Acute intoxicated people are susceptible to injury

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

• Alcohol independent-alcohol withdrawal syndrome maybe anticipated 2-4 days after last drink

  • Increases mortality rate (Riddle, Bush, Tittle, et al., 2010)

  • Symptoms of alcohol withdrawal syndrome: anxiety, headache, insomnia, sweating, high body temp., rapid heart beat, hallucinations, seizures.

Respiratory Status (preoperative)

• Patients undergoing surgery are at risk of respiratory complications because of lying down or coughing.

• Educated with breathing exercise & use of incentive spirometer

Respiratory Infections: Postpone Surgery

• For example, tuberculosis. We have to treat this before we do the surgery.

• With tuberculosis (usually treatment will last 3-6 months), if a patient has it, if the patient is compliant with the first two weeks of medications needed, the patient is considered already noninfectious, so the doctor may decide to postpone the surgery for two weeks after assessment that the patient has TB.

Underlying Respiratory diseases (e.g. asthma)

• We also need to know if there are any underlying respiratory diseases like asthma. If there is asthma for example, patients are nebulized with salbutamol before going to the operating room, and then salbutamol nebulizations are kept ready at the side just in case they have symptoms of asthma during the operation

Other Comorbid conditions, like HIV and Parkinson’s Disease

• HIV is usually always paired with respiratory infections. We really need to assess appropriately.

• Parkinson's Disease, it is a degenerative disorder that affects muscle function, which includes our lungs.

Assess if patient is a smoker, instruct that smoking

should be stopped 4-8 weeks before surgery

We need to let them know that smoking lowers oxygen in the blood and would not help in wound healing

Smokers are more likely to experience poor wound healing (due to low oxygen), SSI (surgical site infection) & VTE (venous thromboembolism)

Components or chemicals in tobacco are known to also damage the vascular system and when there is damage, the body would try to fix it. This may form clots or fibrin and they become thrombosed. If this dislodged and travels the vascular system, then we have embolism and this emboli traveling might go to the brain, to the lungs, to the heart, and other vital organs of the body that may block the blood traveling towards those organs.