nurs320 - periop + perianesthesia

diagnostic surgery

exploratory surgery

palliative surgery

pt. has terminal illness - surgery to make patient life more comfortable

cosmetic surgery

enhance appearance

elective surgery

patient choosing to complete surgery

urgent surgery

patient needs surgery but not ASAP

emergency surgery

patient needs surgery ASAP

surgical risk factors

• age

• nutrition status

• fluid and electrolyte balance

• general health status

• medications

what assessments should the nurse complete pre-op to ensure the patient is ready for surgery?

• H&P exam

• height and weight

• teaching

• medications

• labs & diagnostic tests

• operative site marked by physician

• questions answered

• emotional support

what teachings should the nurse complete pre-op?

know how to manage a drain or walk on crutches so after surgery nurse only needs to RETEACH!

informed consent that needs to completed before surgery

• surgery consent

• anesthesia consent

• blood consent

who can consent to surgery?

• adults

• minors

• emancipated minors

• witness to consent - nurse watches pt. sign consent

• emergency situations - in pt. notes to bring pt. for surgery without consent for life-threatening situation

immediate pre-op assessments

• baseline vital signs

• provide oral hygiene, remove dentures, record loose teeth

• remove nail polish, cosmetics, hair pins, prostheses

• have patient void

• check name band

• review consent

• administer pre-op medications if ordered

• elevate side rails

• complete pre-op checklist

members of surgical team

• surgeon - resident, med student

• surgical assistant

• anesthesiologist or CRNA

• circulating nurse

• scrub nurse/surg tech

• speciality nurse - RNFA

what is “time out” for intra-operative phase?

team verifies for right person, right procedure, right site

ASA classifications

• ASA 1 - healthy (no medical problems)

• ASA 2 - one medical problem (i.e. high BP)

• ASA 3 - more than one medical problem

• ASA 4 0 severe systemic disease

• ASA 5 - not expected to survive without surgery

• ASA 6 - organ harvest (brain dead)

general anesthesia essential nursing assessments and interventions post-op

• breathing tube - airway management

• cardiovascular - hypotension, dysrhymias, MI

• hypothermia - temp less than 95 (OR is cold!!)

• malignant hyperthermia

malignant hyperthermia definition

• chain reaction of abnormalities

• pharmacogenetic disease of skeletal muscle

• inherited disorder - single defective gene

malignant hyperthermia labs

caffeine/halothane contracture test

malignant hyperthermia triggering agents

inhalation agents and depolarizing muscle relaxant

malignant hyperthermia s/s

• early signs - muscle rigidity, tachycardia, dysrhymias

• cutaneous changes

• tachypnea

• pyrexia - hallmark of disease but late sign

malignant hyperthermia interventions

** immediate treatment!!

• discontinue anesthesia/surgery

• administer 100% oxygen

• administer Dantrolene ASAP - reconstitute with 60CC of sterile water

• patient cooling - cool IV fluid and ice

monitored anesthesia care (MAC)

• administered by anesthesia provider

• all IV anesthesia

• patient able to maintain own airway

• many types of agents available

moderate sedation

• administered by non-anesthesia provider who has received special training

• all IV anesthesia

• patient able to maintain own airway

• limited agents available for use

• state laws can vary

assessments when patient enters PACU

• airway, O2

• VS

• anesthesia report

• LOC

• I/O

• pain/comfort

• dressings

• labs

communication hand-off from PACU nurse to med surg nurse

• type and extent of surgical procedure

• type of anesthesia

• Pt. tolerance of anesthesia + surgical procedure

• allergies

• pathologic condition

• status of VS

• type and amount of IV fluids and medications administered

• incisions, dressings, tubes, drains, catheters

• estimated blood loss (EBL)

• any intraoperative complications

• pertinent past medical history

postoperative care assessments

• airway first!! check rate, depth, rhythm; then check VS

• respiratory

  • rate + pattern

  • breath sounds

  • patient’s color

  • use of accessory muscles

  • oxygen

  • pulse oximetry

• neurological - LOC, ability to obey verbal commands, motor/sensory

• renal/urinal system - track I/O

• IV

• GI system - nausea/vomit, GI peristalsis delayed

  • NG tube drainage to decompress and drain stomach

  • promote GI rest

  • allow lower GI tract to heal

• pain assess

  • pain management - oral, IM, IV, patient controlled analgesia

• mobilization

  • sit up in bed and dangle legs post op night for many surgeries

• diet

  • progress from NPO → liquids → soft → house as tolerated

incentive spiromtery

• breathing device to achieve maximal ventilation

• measures respiratory flow or volume

• sitting or semi-fowler

• exhale normally, inhale as slowly and deeply as possible

• 5-10 times every hour

potential complications post-op and nursing care for complications/preventing

• atelectasis, pneumonia, embolus

  • turn, cough, deep breathing

  • maintain hydration

  • early ambulation

  • incentive spirometer

• thrombophlebitis

  • leg exercises while in bed, early ambulation

  • TED stockings, sequential hose (machine blows air into cloth around legs and promotes blood flow)

  • low dose heparin

first dressing change post-op is performed by who?

by physician

hemovac

• self-suction

• canister

• used for orthopedic surgeries

penrose drain

• half of tube inside site, half out

• drains excess fluids

t-tube drain

• used for some abdominal surgeries

• hooked up to gravity bag

wound dehiscence

• separation of the wound edges

• more likely with vertical incisions

• may be caused by a bacterial infection or poor wound healing

• just some of the skin layers tear open

evisceration

• organs with pink, serous drainage come out of wound

• more likely in clients who are older, obese, diabetic, or malnourished

• emergency

prevention of wound complications (dehiscence + evisceration)

• splint incision when coughing

• monitor for signs for infection, malnutrition, dehydration