U3 W8: Surgical client/ pain

blurb: preoperative assessment

patient education, head-to-toe assessment, medical history review, lab results review, diagnostic test review, proper identification, allergies, medications, reactions to anesthesia, use of any tobacco or alcohol, spiritual or cultural needs, pain

Preoperative assessment risk, list chronic conditions that pose surgery a risk

COPD, Sleep apnea, coronary artery disease (CAD), congestive heart failure (CHF)

Preoperative assessment risk: malignant hyperthermia

severe reaction to certain medications given during anesthesia

Preoperative assessment risk: Antigoagulants

increases risk of bleeding during surgery

Preoperative assessment risk: alcohol

increases risk of bleeding, infection, heart problems, increased hospitalization

Preoperative assessment risk: Tobacco

increase risk of blood clots, myocardial infarction

Preoperative assessment risk: Age of over 65 can cause

post op delirium, chronic conditions

Preoperative assessment risk: obesity can cause

risk for higher complications like DVT, or breathing complications

Preoperative assessment risk: Smoking can cause

difficulty with anesthetisa, and breathing, slower wound healing, increased infections

Preoperative assessment risk: diet/ nutrition status

a low status means not very good wound healing.

N/V are normal postoperative events bit what would make this more of an issue?

projectile vomiting

s/s of venous thromboembolism(DVT)

warmth, redness, swelling

s/s of pulmonary embolism

shortness of breath, hypoxia, blue/purple

s/s of hypovolemia

low urine output, decreased and thready pulses, dry mucous membranes, tachycardia, hypotension

s/s of hypervolemia

crackles in the lungs, JVD, pitting edema, 3+ bounding pulses

s/s of ateletasis

hypoactive lung sounds, shortness of breath

what lowers the risk of atelectasis

using an incentive spirometer

dehiscence

staples and sutures opening up

evisceration

organs popped from a wound

s/s of an Ileus

Distended abdomen, hypoactive/no abdomen sounds

s/s of oliguria(low urine output)

pitting edema, dry mucous membranes, JVD, this is also a sign of acute kidney injury

What does a nurse do with getting consent from a patient?

a Nurse cannot obtain consent, it can only witness it

what items can the nurse remove when prepping pt. for surgery?

remove dentures, glassing, hearing aids, piercings

the universal protocol

prevents wrong patient, wrong site, wrong surgery

When is time-out given?

before anesthesia

Time-out

correct pt. by name and DOB, correct procedure, consent form for correct site, and marked surgical sitewh

Discrepancies: If marked site and patient say something different (or anything doesn't match

stop the procedure, clarify correct patient and procedure, if it is still wrong, do not continue with surgery

circulating nurse

circulates the operating room(not sterile)

what are the duties of a circulating nurse?

• coordinates pt care

  • verifies identity, assess allergies, checks consent forms

• assisting anesthesia provider as needed

• safety, positioning, and monitoring of pt

• provide supplies

• counts instruments

• documents information

The surgical environment has these things within it.

cold(65F-75F) humidity(20-60%), sterile technique and attire including gown, mask, gloves, hair cover, shoe covers

Skin preparation

by showering, shaving, cleansing with iodine, chlorhexidine alcohol, scubbing in a circular fashion and move outward, use a new sponge for each area

monitoring local anesthesia

tachypnea/tachycardia, tinnitus, numbness around the mouth, drowsiness, metallic taste, tremors, seizures, coma
report

regional anesthesia

temporary loss of feeling in localized areas of the body

general anesthesia

nervous system suppressant, used in invasive procedures and uses respiratory support

moderate sedation to monitor for

blood pressure, respirations and oxygen saturation

respiratory status in a post operative

primary concern. assessing rate, depth, and oxygen saturation.

hep suction secretions

use an incentive spirometer to prevent pneumonia and atelectasis

cough and deep breathing exercises

assessing Cardiovascular system post op

assess circulation

fluid/electrolyte imbalance(like increased K+lvs)

frequent vital signs

assess extremities, pulses, DVT

prevention: early ambulation, SCDs(Sequential Compression Devices) and TEDs (Thromboembolic Deterrent stockings) positioning

assess the cardiovascular system/ s/s of bleeding

hypotension, tachypnea, changes in LOC, decreased O2, weak thready pulse, tachycardia, decreased urine output

neurological assessment post op

the goal is baseline neuro.

integumentary assessments post op

assess dressings for excessive bleeding, and monitoring for infection: pain, redness, inflammation, temp above 100.4, increased WBCs, tachycardiap

pain management

use of a PCA and nonpharmacological interventions like distractions, music, breathing, heat/cold, repositioning

positioning post op

reposition frequently, prevents blood clots, pneumonia, atelectasis, and muscle weakness, you can splint with a pillow during coughing for chest /abdominal incisions to reduce pain and protect wound

gastrointestinal complications post op

auscultating bowel sounds and asses for N/V

early ambulation to promote gastric motility and prevent ileus

abdominal surgeries are at high risk for ileus(because the surgons’s were manipulating the GI system)

Renal complications post op

monitoring output, strict I&O, assessing for skin turgor, mucous membranes, eyes, skin tenting for dehydration

Safety considerations:
Increased Risk for Falls

Due to grogginess, pain, weakness post-op. Older patients (>65) are more susceptible

Interventions: for the risk of fall pts

Keep room free of tripping hazards, monitor for medications causing dizziness (e.g., opioids)

Nausea/Vomiting & Aspiration: interventions

Raise head of bed to prevent aspiration, Keep patients upright for at least one hour after meals, Cut food into small bites

monitor for confusion or delirium

keep patient safe during their LOC

Acute pain

last 6 months or less, sudden onset, has an end, anticipated or predictable

Chronic pain

sudden or slow onset, constant without anticipated end, can be arthritis, back pain, migraine, headaches

nociceptive pain (damage from an outside source

skin, bones, joints, muscles, connective tissue, internal organs, skin or subcutaneous fat, damage to body tissue, sharp, stabbing, throbbing, “shocking pain”

neuropathic pain(damage from the nerve cells)

nerve pain, diabetic neuropathy(feels like pins and needles), phantom limb pain, spinal cord injury, intense, shotting, burning, “pins and needles”

Cancer pain

comes from a tumor, the bone, or the treatment of these these things. could also be caused by post surgical, radiation or chemotherapy induced neuropathy

Age considerations: children

pain may be ignored, but their behavior and physical signs will show their pain.

FLACC

pain scale for children 2 months to 7 years, rated by observation

wrong BAKER faces

for children 3 and up to rate their pain

CRIES

for infants born 38 weeks of greater.

age considerations: older adults

back pain may be consistent, neuropathy pain, decreased pain tolerance, chronic illness, arthritis

age considerations: special needs

may not be able to express their pain so look at their behavior, like grimacing, guarding, crying, restlessness

objective signs of pain

Can be measured/observed
by the nurse
 Crying
 Sweating
 Restlessness
 Grimacing
 Guarding
 Tachycardia
 Tachypnea
 Hypertension

Preipitating cause

This refers to what makes the pain worse or brings it on

Quality

This asks what the pain feels like
EX: aching, stabbing, sharp, throbbing, dull, burning, cutting, gripping, tearing, pounding, and shocking pain

Region

This identifies where the pain is located and if it spreads to other areas

Severity

This assesses how severe the pain is, often rated on a scale of zero to ten

Timing

This asks how long the pain has been going on (its onset and duration)

pharmacological Interventions for pain

Opioids
Premedicate before painful procedure
Try to prevent breakthrough pain
Treat pain before it becomes severe
Patient Controlled Analgesia (PCA pump)
NSAIDs (ibuprofen, naproxen, Aleve, Advil)
Acetaminophen
Monitor for respiratory depression in opioids & bleeding in NSAIDs
Some cultures may refuse opioids

nonpharmacological interventions for pain

Positioning (turn Q2)
Relieve bony prominences
Cold
Heat
Massage
Distraction
Therapeutic touch
Splint post-op incision with a pillow