Nurse120 week 1: Periop & electrolytes

Phases of Care

The three phases are:

• Preoperative (before surgery)

• Intraoperative (during surgery)

• Postoperative (after surgery).

Main Pre-op Nurse Duty

• The primary responsibility is Assessment/Data Collection.

• This involves obtaining the client’s health information, identifying risk factors, providing surgical education, ensuring patient readiness, and establishing baseline data.

Informed Consent

• The Provider/Surgeon is responsible for obtaining consent.

• The Nurse witnesses the client's signature, confirming the client understands and is competent. 

• No consent is needed in a life-threatening medical emergency.

Pre-op Teaching

Essential topics: 

• Pain management (e.g., PCA)

• Incentive Spirometer use (10x every hour)

• Turn, Cough, and Deep Breathing (TCDB)

• Instruct the patient to splint the incision when coughing to reduce pain and prevent dehiscence.

Allergies & Risk (Latex) & iodine 

latex:

• bananas

• eggs

• avocados

• kiwi

• chestnuts

• potatoes

• peaches 

A latex allergy is a risk for anaphylaxis (a potential oxygenation problem).

iodine/contrast:

• shellfish 

Herbal Supplements

• Supplements like the "4 Gs" (Ginkgo, Garlic, Ginger, Ginseng) increase the risk for bleeding

• They should typically be held 7-10 days before surgery.

NPO & Prophylactic Antibiotics

• Clients should be NPO (nothing by mouth) for a minimum of 8 hours prior to surgery

• Prophylactic antibiotics (e.g., Cefazolin) must be administered 30-60 minutes prior to the surgical incision to prevent infection

Intra-op Safety (Time Out)

• The Time Out utilizes the Universal Protocol/NPSG (National Patient Safety Goal)

• It ensures the Right Patient, Right Body Part (marked with indelible pen), and Right Procedure

• Wrong site surgery is a Sentinel Event (Never Event).

Surgical Team Roles

Circulating Nurse

• Non-sterile

• performs Time Out

• is the patient's advocate

• manages documentation

• gives handoff report to PACU

• sets up room NOT STERILE FIELD

• not scrubbed, gowned, or gloved

• can go in/out of OR

Scrub Nurse

• Sterile

• surgical hand antisepsis

• assists the surgeon

• performs activities within the sterile field

• gowned and gloved in sterile attire

• correct count of supplies

• prepare and manges sterile field and instrumentation

Malignant Hyperthermia (MH)

A rare genetic disorder triggered by anesthetic agents (e.g., Succinylcholine)

S/S

• muscle rigidity/spasms 

• a rapid, high rise in body temperature (up to 105-106°F)

The essential antidote is Dantrolene.

Anesthesia Antidotes

Opioids (e.g., Fentanyl, Morphine)

• antidote: Naloxone

Benzodiazepines (e.g., Midazolam, Lorazepam)

• antidote: Flumazenil.

Post-op Complications

• Anesthesia causes central nervous system (CNS) suppression

• decreasing vital signs, level of consciousness, temperature, and peristalsis

Expected early complications

• Atelectasis

• low temperature (due to anesthesia effects)

• decreased GI motility

PACU Discharge

• Recovery is monitored using the Modified Aldrete Scoring System

  • A score of 7 to 10 is required for discharge/transfer

• Criteria include stable vital signs, O2 saturation >90%, return of gag reflex, and pain/nausea control

Wound Healing Complications

Dehiscence: Separation of wound edges. 

Evisceration: Protrusion of abdominal organs through the incision. 

• Action for Evisceration

  • Cover immediately with a sterile dressing soaked in sterile saline and notify the provider.

Wound Drainage

Expected Drainage

• Serous (clear/yellow)

• Sanguineous (red/bloody)

• Serosanguineous (pink)

Infection/Unexpected Drainage

• Purulent (yellow/green, thick, malodorous)

Nursing Process (RN)

Sequential steps are: 

• Assessment (Recognize Cues)

• Analysis (Analyze Cues & Prioritize Hypotheses)

• Planning (Generate Solutions)

• Implementation (Take Actions) 

• Evaluation (Evaluate Outcomes)

Nursing Process (PN)

Sequential steps are: 

• Data Collection

• Planning

• Implementation

• Evaluation 

PNs work under the supervision of an RN

Non-Delegable Tasks

Tasks requiring clinical judgment or assessment cannot be delegated to assistive personnel (AP/UAP).

Examples

• developing the plan of care

• providing primary teaching

• assessing new wounds

• administering IV medications

• suctioning/tracheostomy care (in some states)

Maslow's Priority

Priorities start with Physiological Needs

• These include oxygenation, circulation, hydration, nutrition, elimination (e.g., voiding), and shelter.

• The next highest level is Safety and Security (e.g., fall prevention).

Critical Thinking Level (Commitment)

The highest level, characterized by acting autonomously and fully assuming responsibility for choices, based on expert knowledge and experience.

Normal Ranges (Na+, K+)

Sodium (Na+): 136 to 145 mEq/L. 

Potassium (K+): 3.5 to 5.0 mEq/L.

Fluid Volume Deficit (FVD)

Caused by excessive vomiting, diarrhea, sweating, or blood loss.

S/S

• Hypotension

• Tachycardia

• confusion

• dry oral mucous membranes

• poor skin turgor

Labs: High Hct, BUN, Urine Specific Gravity (>1.030).

Fluid Volume Excess (FVE)

Caused by excess IV fluid administration or conditions like heart failure.

S/S

• Bounding pulse

• Crackles (in lungs)

• Distended neck veins (JVD)

• edema

• hypertension

IV Fluid Types

Isotonic

• e.g., 0.9% Normal Saline, Lactated Ringer's

• Used for volume replacement

Hypotonic

• e.g., 0.45% Saline

• Shifts fluid into cells

Hypertonic

• e.g., 3% Saline, 50% Dextrose

• Draws fluid out of cells

Hypokalemia (<3.5 mEq/L)

Causes

• Excessive GI losses (Vomiting, Diarrhea, NG tube suctioning)

Major Concern

• Cardiac dysrhythmias

S/S

• skeletal muscle weakness

• decreased GI motility

• paralytic ileus

Hyperkalemia (>5.0 mEq/L)

Major Concern

• Cardiac dysrhythmias (bradycardia)

S/S

• weakness/paralysis

• intestinal cramping/hyperactivity

Hypocalcemia

Assessment

• Positive Chvostek sign 

  • facial twitch when tapping cheek

• positive Trousseau sign 

  • hand/wrist flexion with BP cuff inflation

Sodium Imbalance S/S

Hypernatremia (Water Loss/Dehydration)

• Thirst

• fever

• dry mucous membranes

• CNS changes (restlessness, confusion, seizures)

Hyponatremia (Water Excess/Dilution)

• CNS changes (lethargy, confusion, headache, seizures)

Pancreatic Function

• The pancreas secretes

  • Insulin (from beta cells) to lower blood glucose and allow cellular absorption of glucose

  • Glucagon to prevent hypoglycemia

• It also functions as an exocrine gland, secreting digestive enzymes.

Hyperglycemia Management

Immediate priorities

• Identify blood glucose levels and initiate prompt treatment to prevent crisis.

• Teaching includes

  • monitoring for ketones (in urine)

  • improving hydration

  • adjusting diet/exercise

• Exercise is not recommended if ketones are present.

Hypoglycemia Management

• If the client is awake and alert, follow the 15-15 Rule (15-30g of fast-acting carbohydrates, such as 4 oz 100% fruit juice

  • 4-6 oz juice, soda (not diet)

  • 1 tbsp honey/sugar

  • glucose tablets

  • 6-10 pieces hard candy

  • 8 oz milk

• If unable to swallow or consciousness is altered, administer glucagon, IV D50

HbA1c

• Hemoglobin A1C measures the client’s average blood glucose level over 2 to 3 months.

• A healthy range is 4% to 6.5%.

Macronutrients

• Macronutrients are eaten in large amounts and provide energy.

  • Protein (building block for tissue repair)

  • Carbohydrates (primary fuel source, turned into sugar for energy) 

  • Fat (helps absorb vitamins, provides energy)

High Glycemic Index

• Foods like potatoes, white bread, and processed snacks raise blood glucose levels rapidly

• Low glycemic index foods (e.g., legumes, vegetables) raise glucose levels slowly

Nutritional Assessment Tools

• Tools include 24-hour recall (what was eaten in the last day) and food frequency questionnaires (typical consumption based on a list)

• Nurses also check BMI, lab results (e.g., cholesterol), and assess hair, skin, and teeth

post op temp

• ~12H

  • Hypothermic ≤ 96.8: effects of anesthesia, loss of body heat

• 48H

  • Mild elevation ≤ 100.4: inflammatory response to surgical stress

  • Mod elevation > 100.4: lung congestion, dehydration

• 3 days post-op

  • If temp is >100 = infection

When to call DR. (3 days post-op: if temp is >100 = infection)

Nursing Management: Cardiovascular Problems

Notify the ACP or HCP if:

• Systolic BP <90 mm Hg or >160 mm Hg

• Pulse <60 bpm or >120 bpm

• Difference between systolic & diastolic BP (pulse pressure) narrows

• BP trends gradually decr. OR incr.

• Irregular heart rhythm

Atelectasis

S/S

• Tachypnea

• hypoxia (anxiety, confusion, change LOC)

• diminished/ no breath sounds

Tx

• Deep breathing & coughing

• incentive spirometer

• splint the incision, position the client on unaffected side

Jackson-Pratt drainage (closed system)

• When emptying and closing it, flatten it, and put the cap back on

• NO more than 200 cc drainage PER SHIFT.

Penrose drainage (open system)

Rubber placed inside wound to allow excess fluid (like blood or pus) to drain out.

Local infection

• Redness

• heat

• pain

• swelling

• loss of function

System infection

• Increased WBC

• Fever

• confusion + change in LOC (older)

types of surgery

Elective surgery:

• Planned, non-urgent procedure scheduled in advance to improve quality of life or address non-life-threatening conditions

  • cosmetic 

  • cataracts

Emergency Surgery:

• Unplanned, urgent procedure performed immediately to treat life-threatening or severe conditions.

  • Appendectomy

Inpatient (Same-Day Admission) Surgery:

• Overnight (complex surgeries).

Ambulatory (Outpatient or Same-Day) Surgery

• Go home the same day w/o requiring an overnight hospital stay (minor surgeries).

  • Laparoscopy

★ Most surgeries are Ambulatory (Outpatient)

physical environments of the operating room 

unrestricted 

• staff and others in street clothes can interact w/ those in surgical attire 

semi-restricted 

• staff must wear surgical attire and cover all head and facial hair

restricted 

• includes OR, sink area, and sterile core

• staff must wear masks in addition to surgical attire 

holding area

• conduct pre procedure verification

• assess patient 

• mark procedure site before transferring patient into OR for surgery