Week 4: Perioperative Care

AORN (association of perioperative registered nurses)

provides guidelines for ethical and safe care for patients undergoing operative and other invasive procedures

diagnostic surgery

breast biopsy, joint arthroscopy

surgical cure

removal of cancerous tumor or gall bladder

palliation surgery

improve QOL by reducing symptoms; thoracentisis to drain fluid to reduce pain

reconstructive surgery

total hop replacement

surgical care improvement plan (SCIP)

set of core compliance measures to reduce surgical complications

team STEPPS

system designed to facilitate communication between healthcare providers to enhance pt safety and quality of care

preoperative stage

begins when pt is scheduled for surgery, ends at time of transfer to surgical suite; focus is on preparing for surgery and ensuring safety

intraoperative stage

transfer to operating suite

postoperative stage

begins after completion of the surgery and transfer to the PACU or ICU for monitoring

pre-op assessment

history with review of systems, medical and surgical history (including anesthesia history), drug and substance use; begin discharge planning

chronic illnesses that increase surgical risk

diabetes: delayed wound healing

RA: special consideration to positioning on the operating table

patients with cardiac problems: risk for MI

smokers: increased risk of pulmonary problems, pneumonia, atelectasis

chronic lung diseases (asthma, chronic bronchitis): problems of oxygenation during surgery

family history and problems with anesthetics

may indicate reactions to anesthesia such as malignant hypothermia (inherited muscle disorder, life threatening complication to drugs used during anesthesia)

pre-op physical assessment

obtain base vital signs, assess detailed head to toe

pre-op diagnostic assessment

need baseline data to help predict possible complications

urinalysis; blood type and screen; CBC or Hgb & Hct; clotting studies; metabolic panel (low K may slow recovery from anesthetic, high K increases risk of dysrrhythmias); pregnancy test; chest x-ray; CT, MRI, ECG (routine for >40/45 y/o)

pre-op health teaching

assess the patient’s current knowledge

provide basic information (someone to drive them home, printed info); ensure informed consent is obtained; ensure site marking; implement dietary restrictions (NPO reduces the risk of aspiration, may develop fluid and electrolyte disturbances, ESP eldery); blood sugar (don’t give insulin if they are not eating) ; discuss scheduled drugs; explain intestinal and skin preparation; explain tubes, drains, vascular access; prepare patient for post op procedures (frequent vitals, checking dressings etc); teach methods to prevent respiratory and cardiovascular complications

incentive spirometer

promotes lung expansion and helps prevent atelectasis 10 breaths every hour

coughing and splinting

use a pillow; helps expel secretions, keeps the lungs clear; allows full aeration and prevent pneumonia and atelectasis

informed consent

patient has sufficient information about their surgery

adequate disclosure (nature and reason for the surgery, who will be performing the surgery, who else will be there); all available treatment options with their risks and benefits; expected outcomes, risk of anesthesia, the use of blood products

surgeons responsibility to make sure the patient has a clear understanding (nurse is not responsible for providing detailed information about the procedure, can clarify what the sugeon has said)

nurse must verify that the consent form is signed dated and time; may serve as a witness

consent must be signed by the patient before any premeds are given

two healthcare personnel can sing consent form if pt needs emergency surgery ans no family is available

preoperative EHR review

ensure all documentation, preoperative procedures, orders are complete; check surgical consent form for signature; confirm procedure is in agreement with consent form; ensure site marking (surgeon); document allergies, height, and weight; ensure all laboratory and diagnostic test results are in chart and abnormal results noted; notify the surgical team of special needs, concerns, instructions

pre-op patient preparation

remove clothing and provide gown; leave valuables with caregiver or lock up; ensure pt is wearing ID band; apply allergy band if indicated

patient transfer to surgical suite

review/update EHR; reinforce teaching; ensure pt is properly dressed

administer any prescribed pre-op drugs: benzodiazepines (diazepam, lorazepam); anticholinergics (atropine (to dry mouth secretions), scopolamine); opioids (morphine fentanyl); antiemetics (ondansetron (Zofran), prochlorperazine, metoclopramide): antibiotics (ceftriaxone (Rocephin), broad spectrum); beta blockers (metoprolol (slows the heart, improves conduction, relaxes blood vessels and lowers blood pressure))

unrestricted area

holding area(preanesthesia care unit, presurgical unit; preoperative preparations completed here), staff locker room

semi restricted areas

surrounding support areas; preoperative meds given if not given on the unit, conscious sedation started, patients vital signs monitored

restricted areas

OR ( restricted entrycontrolled environmentally and bacteriologically, positive pressure ventilation, UV lighting), scrub sink

circulating RN

does not scrub up; manages patient care in the OR suite, pt positioning, skin prep, meds, specimens, warming devices, surgical counts and dressings

responsible for the care of the patient during surgery, including preventing injury and complications related to anesthesia, surgery, positioning and equipment use, also to protect the patient’s dignity and rights

scrub RN/tech

has thorough knowledge of the procedure and can anticipate the instruments the surgeon need

RNFA (registered nurse, first assistant)

new role (extra education and training); participates in the procedure including suturing

anesthesia care provider

anesthesiologis: MD

nurses can become nurse anesthetists (by 2025 will need a doctorate)

surgical scrub

scrub with betadine or chlorhexadine, hands to forearms to elbows

surgical attire: gown and gloves, hospital provided scrubs, caps, mask, eye protection, shoe covers

nurse responsibilities on patient admit

ID the patient, questions, valuables/prosthesis, NPO, preoperative meds

assessment for operations

clinical status, skin integrity esp around the proposed surgical site, areas that may be affected by positioning on the table

planning for operations

patient centered goals and outcomes, keep the patient safe (risk of thermal injury from the grounding pad (electrical cautery)); responsible for ensuring an aseptic environment, conducting instruments and sponge counts, managing specimens, use of equipment

implementation for operations

physical prep (getting the patient on the OR table safely and in the right position), setting up monitoring, keeping the patient warm to prevent hypothermia, bear huggers; aware of allergies (especially latex)

documentation (circulating nurse keeps an accurate record of patient care activities, usually a standardized form or flowsheet in the EHR)

evaluation in operations

circulating nurse conducts ongoing evaluation; I&O’s and vital signs are recorded by the anesthesiologist, dressings, specimens, meds, inspects the skin under the grounding pad and pressure areas

safety in the OR

risk for injury: infections, physical trauma, physiologic effects

fire: electrosurgical units, lasers, fiberoptic light sources; fuel source (surgical drapes, alcohol based skin preps); oxidizer (oxygen, nitrous oxide)

time-out procedures: prior to start of surgery, all team members participate, ID patient, check surgical site

time out procedure

before skin incision, all other activities suspended

introduction of team members; confirm patient’s identity, procedure, incision site, consent, site marked and visible; fire risk assessment; relevant images properly labeled and displayed; equipment concerns

scrub person and RN circulator confirm sterilization indicators, additional concerns

RN documents completion of time out

positioning of patient in the OR

allow for accessibility of operative site, administration and monitoring of anesthesia, maintenance of airway

prepping the surgical site

scrubbing or cleansing the site: surgical tech or RN (scrubbed up), circular motion, clean to dirty, with betadine or chlorehexadine (wait 3-5 mins to dry)

drape the patient: only leave site to be incised exposed

malignant hyperthermia

an inherited muscle disorder which is acute and life threatening; causes inadequate thermoregulation, increase in Ca and K leading to acidosis, cardiac dysrhythmias, and high body temp

immediate post-op

report from OR to PACU, anesthesiologist report, circulating nurse report

post-op phase 1

immediately after surgery in PACU (patients may go directly to ICU)

PACU nurse receives report for circulating nurse, anesthesiologist, surgeon at the patient’s bedside; multidisciplinary approach; ensures pt is breathing first; obtains vitals signs q15min

post-op phase 2

prepares patient for care in extended care environment: med surg unit, telemetry, ICU, same day surgery unit (AKA ambulatory care), discharged home

PACU nurse prepares patient for extended care environment or discharge home, evaluates patient’s readiness to be d/c’d from PACU

post-op phase 3

extended care environment: med surg unit, telemetry, ICU

PACU nurse transfers to surgical unit (or telemetry, ICU); SBAR report from PACU to receiving nurse (primary nurse) usually by phone, how well they woke up, any complications etc

primary nurse will check ABC’s and vital signs, then conduct a thorough patient assessment including looking at wounds drains, pressure areas

PACU nurse

skilled in care of patients with multiple problems after surgery; has ACLS (advanced cardiac life support) training; makes knowledgeable, critical decisions if needed; facilitates discharge (if ambulatory care) or hands off to nurse generalist ( RN on med/surg unit, when patient is stable)

preparing for post-op patient

Annotate picture draw or write, Vitals Machine, Emesis basin, Incentive spirometer, Clean gown. IV pole/ pump, Suction equipment, Oxygen, Extra pillows, Chucks, Warm blankets

hypothermia

cool temperature in OR, use warm blankets or a Bair Hugger to warm them up (increasing body temperature raises metabolism and improves circulation/respiratory function)

Shivering – sometimes a side effect of certain anesthetic agents. Clonidine can be used in small doses can decrease the shivering. Encourage deep breathing and coughing to expel anesthetic gases

Malignant hyperthermia – Results in a hypermetabolic state, high intracellular calcium ion concentration, high plasma conc of potassium. High co2 metabolic and respiratory acidosis. Multiple organ failure. Can be lethal. Early signs are tachypnea, tachycardia, arrythmia’s, hyperkalemia and muscle rigidity. Monitor patients at risk very carefully. Dantrolene sodium (muscle relaxant) is treatment

post-op neuropsychologic assessment

pain, fever, delirium, hypothermia, postoperative cognitive dysfunction

post-op respiratory assessment

airway obstruction, hypoventilation, aspiration, atelectasis, pneumonia, hypoxemia, pulmonary embolus, bronchospasm

post-op cardiovascular assessment

dysrhythmias, hemorrhage, hypo/hypertension, superficial thrombophebitis, veinous thromboembolism

post-op GI assessment

nausea, vomiting, distention, flatulence, postoperative ileus, hiccups, delayed gastric emptying

post-op urinary assessment

retention, infection

post-op integumentary incision site) assessment

infection, hematoma, dehiscence

post-op fluid and electrolyte assessment

fluid overload, fluid deficit, electrolyte imbalance, acid-base disorders

respiratory system post-op

first priority

assess for patent airway, adequate gas exchange; note artificial airway; oxygen delivery device, if applicable; check lungs q 4 hrs for first 24 hours following surgery

cardiovascular system post-op

assess vitals and compare with baseline; report BP changes that are 25% higher/lower than baseline; monitor for cardiac depression, fluid volume deficit (IV fluid to replace loss), shock, hemorrhage, and drug effects; apply antiembolism stockings and pneumatic compression devices (remove once a shift, ensure no wrinkles) if ordered

neurologic system post-op

assess cerebral function and level of consciousness (simple commands); orientation to person, place, time and situation; motor and sensory function (specific assessments for spinal anesthesia)

fluid, electrolyte, and acid-base balance post-op

assess I&O, hydration status (color/moisture of mucus membranes, turgor, drainage on dressing, fluid imbalance), IV fluids (usually isotonic 0.9% NS or LR, or D5LR), acid–base balance (NG tube drainage)

renal/urinary system post-op

assess retention of urination (pre-op drugs/anesthetic agents can lead to urinary retention), effects of drugs on urination, signs of urine retention

report urine output <30 ml/h or dark/concentrated urine; patients should urinate within 8-12 hours post op

GI system post-op

assess postoperative nausea/vomiting (PONV) (patient in sidelying position), intestinal peristalsis (physical activity and early ambulation help stimulate return), NG drainage, constipation

post operative ileus

non mechanical obstruction of the bowel; decreased peristalsis

S&S: distended abdomen, pain, vomiting, no gas or stool (there may still be bowel sounds)

integumentary system post-op

normal wound healing (retains tissue integrity in ~2 weeks); assess tissue integrity frequently; drainage (q8h)

impaired wound healing is seen most often between 5 and 10 days after surgery: dehiscence (split open), evisceration (wound opens and gut fall out

sanguineous drainage

bloody

serosanguinous drainage

light red/pale pink

serous drainage

serum like/yellow

penrose drain

gravity drain; soft, flexible latex tube to remove blood, pus, or fluids from a surgical site or abscess

jackson-pratt drain

drainage collects in a collecting vessel by means of compression ans re-expansion of the system

pain assessment post-op

pain/discomfort expected after surgery; continuous assessment needed (especially after giving pain medication), physical and emotional signs of pain, ask patient to rate pain on 0-10 scale

most surgical pain within the first 24-48 hours following surgery

morphine (opioid) most common post op med for pain relief in initial post op period; initially IV transition to PO meds; Non-opioids (NSAIDS, muscle relaxants- Flexeril (cyclobenzaprine)); non-pharmacological interventions

psychosocial assessment post-op

assess for signs of anxiety , reassure patient of safety, assess caregiver, refer as needed

emergence delirium (waking up wild!) more likely with children

delayed emergence – If patient needs painful stimuli to wake up – notify anesthesiology immediately

laboratory assessment post-op

analysis of electrolytes, CBC, urinalysis, kidney function tests, ABG (for pts who have resp or cardiac disease, had chest surgery or on mechanical ventilation post op)

patient priorities post-op

Potential for decreased gas exchange due to the effects of anesthesia, pain, opioid analgesics, and immobility

Potential for infection and delayed healing due to wound location, decreased mobility, drains and drainage, and tubes

Acute pain due to the surgical incision and procedure, and surgical positioning

Potential for decreased peristalsis due to surgical manipulation, opioid use, and fluid and electrolyte imbalances