Perioperative Nursing Care and Processes

Perioperative Care

care that clients receive before, during, and after surgery

Informed Consent

Client's agreement after understanding procedure details.

-description of procedure and alternatives

-name and qualifications of person performing the procedure

-risks/benefits

-explain right to refuse

-explain natural disease process and its course

-explain expected outcome, recovery, rehab plan and treatment course

-must make sure patient understands

Nurse role during consent

-not getting the consent but Witnessing

medication safety after surgery

-patient can be AAO x4 but overestimates ability while on medication or forget what wires and IV they are attatched too annd can fall

interventions

prevent blood clots, venous thrombus, pulmonary embolism

-ambulation is the most important thing

pulmonary safety after surgery

cough/deep breath (2 hrs)

-incentive spirometer (10-20x an hour) (blow out, suck slow and deep to fully expand the lungs)

encourage pain meds

so patient is more comfortable ambulating or doing respiratory exersizes

report

abnormalities

to prevent DVT

-early ambulation

-compression stockings/ted hose

Preoperative Phase

Begins with surgery decision, ends before surgery when client is transferred to OR or procedure bed

Intraoperative Phase

Begins at OR transfer, ends at PACU transfer.

Postoperative Phase

Begins at PACU admission, ends with recovery from surgery and follow up with MD.

Surgical procedures are classified in 3 ways

1.urgency

2.Risk

3.purpose

Elective Surgery

Surgery planned in advance, not urgent.

Urgent Surgery

Requires prompt attention but not emergency.

Emergency Surgery

Immediate surgery needed to save life.

risk could be either

minor or major

Purpose could be

-diagnostic (biopsy)

-curative (removal of mass)

-preventative

-ablative

-palliative (wont cure but increases comfort)

-reconstructive (boob job)

-transplantation

-constructive

anesthesia states

-Loss of consciousness​ (for endoscopy or colonoscopy deep sleep)

-Amnesia ​ (forget it)

-Analgesia​ (pain meds)

-relaxed skeletal muscles​ (intubation)

-Depressed reflexes (intubation)

General Anesthesia

Induces loss of consciousness via inhalation or IV.(Intubation/ventilator)

-patient needs to be cleared by cardio or respiratory

pacemaker patient?

need to be checked B4 surgery call manufacturer

Regional Anesthesia

Blocks sensation in specific body area by injecting anesthetic agent near a nerve or nerve pathway around operative site.

-obstetric, knee, bone

Topical Anesthesia

Applied to surface of skin or mucous membranes.

-burns/open wounds

Moderate Sedation analgesia

Used for short, minimally invasive procedures. (conscious sedation/analgesia)

Induction Phase

From anesthesia administration to incision readiness.

Maintenance Phase

From incision to near procedure completion.

Emergence Phase

Client wakes from anesthesia, ready to leave OR.

types of regional anesthesia

-nerve blocks

-spinal

-epidural

nerve block anesthesia

bone replacement shoulder knee hip

spinal anesthesia

obstetrics/back surgery

epidural

delivering a baby

if patient does not understand the procedure from the physician

call them back to explain

Advanced Directives

Legal documents outlining patient's healthcare preferences.

-nurses responsibility with informed consent

-includes living will and durable power of attorney

living wills

A legal document stating a person's desires on what measures should or should not be taken to prolong life when his or her condition is terminal.

Durable power of attorney

exists when person executes a person as power of attorney which will become or remain effective in the event he or she should later become disabled can even be chosen by patient if they are AAOx4

NANDA

Nursing diagnosis classification system for patient care.

nursing process for perioperative care

-Assessment ​

-Health history​

-Medical history

-allergies (previous reactions to anesthesia)​

-Physical assessment​

-diagnosis

-nanda

​-Impaired comfort​

-Risk for infection

-OI/ planning

-Implementing

Client Risk Factors

-Developmental level​

​-Medical history​

​-Medications​

​-Previous surgeries​

​-Nutrition​

-Use of alcohol, illicit drugs, or nicotine​

​-Activities of daily living and occupation​

​-Coping patterns and support systems​

​-Sociocultural needs​​​

stop blood thinners

7 days before surgery

nutrition is important

it influences healing

medications

some may need to be given even if HCP says they are PO (ask Dr)

alcohol/illicit drugs

could influence heart rate and also may need to up-dose drugs

sociocultural needs affect

transplant patients, can they afford after care and necessary medications

tests before surgery

-CBC

-CMP

PTINR

-COMPLETE PANEL

-12-LEAD ekg

-If previous heart issue they need Eccho

-verify labs

-F- pregnancy tests

patient belongings

-make sure you remove everything a secure

jewelery, underwear

-dentures, hearing aids, contacts, glasses

(document what they had with them how you secured it or if you send it home with a family members.

anticoagulants

precipitate hemorrhage

-stop these​

herbal meds

-can stop blood clotting

Diuretics

electrolyte imbalances, respiratory depression from anesthesia​

Tranquilizers

increase hypotensive effects of anesthetic agents

Adrenal steroids

abrupt withdrawal may cause cardiovascular collapse

(prednisone/cortisone)

-we want to gradually withdraw them

-elevate glucose level and impact healing

Antibiotics in mycin group

respiratory paralysis when combined with certain muscle relaxants​

if you notice these medications on your patients MAR

-notify physician and ask if you should hold

Pre-Surgical Screening

-chest xray

-ECG

-CBC

-Electrolyte levels (basic metabolic panel or complete metabolic panel)

-urinalysis

other screening dependent on client individual history

-female-pregnancy tests

nursing role in pre-surgical testing

-Ensure that tests are explained to the client.​

-Ensure that appropriate specimens are collected.​

-Ensure that results are recorded in client records before surgery.​

-Ensure that abnormal results are reported.​

CONTACT HCP​

Teach client

-Surgical events and sensations​

-Pain management​

-Physical activities​

1.Deep breathing​

2.Coughing​

3.Incentive spirometry​

-Leg exercises​ (foot pumps)

-Turning in bed​

-Early ambulation​

​(get patient to walk from PACU to bed to expel carbon dioxide)

Nursing Interventions to meet psychological needs

-Establish therapeutic relationship and allow client to verbalize fears and concerns.​

-Use active listening skills to identify anxiety and fear.​

-Use touch to demonstrate genuine empathy and caring.​

-Be prepared to respond to common client questions about surgery.​

never give

false reassurance

leg exersises to increase venous return

preoperative prep

-Hygiene and skin preparation​ (chlorahexidene shower twice night before surgery and morning of eliminates bacteria on skin)

-Elimination​

-Nutrition and fluids​ (NPO needs fluid and diabetic must have dextrose)

-Rest and sleep​

-Preparation and safety the day of surgery ​(family must pick them up no ride share)

Intraoperative care

Assessment ​

-Pre-op completion​

-Marking site​

-Diagnosis- NANDA​

Risk for imbalanced fluid volume​

Risk for injury​

​-Outcome identification /planning​

-implementing​

-Documenting ​

-Evaluating​

-time out before to make sure all info is correct

normal urinary output

30 cc an hour

Postoperative Assessments

-Monitoring vital signs and recovery status.

-empty all drains /CATHETERS from PACU

-​Helps you get accurate I/o

-COUNT ALL SPONGES AND MATERIALS USED

vital signs post op

- q15x4 (first hour)

-q30x2 (next hour)

-q1 hr x4 (every hour for the next 4 hours)

-systematic assessments every 10-15 mins

timeout

-verify patient name

-surgeon

-procedure

return of conciosuness

-make sure patient is AAO

-give small amount of liquid to make sure they can swallow

abdominal patient

-check back for bruising could be hematoma

-if patient is hypotensive and tachycardic could be bleeding

Ongoing Postoperative Care

-Assessment​ (CBC vitals head to toe)

-Diagnosis​

-Acute pain​

-Risk for delayed surgical recovery​

-Outcome

identification and planning​

-Implementing ​

-Evaluation

Postoperative Assessments and Interventions

Respiratory status (airway, pulse oximetry)​

Cardiovascular status (blood pressure and heart rate)​

Temperature​

Central nervous system status (level of alertness, movement, shivering)​

Fluid status​ (NS /LR)

Wound status​

Gastrointestinal status (nausea and vomiting)​

General condition​

Important: Note comparisons with preoperative baseline values​​

Outcomes for surgical client

Receive respectful and culturally and age-appropriate care​

Be free from injury and adverse effects​

Be free from infection and DVT​

Maintain fluid and electrolyte balance; skin integrity, normal temperature​

Have pain managed​

Demonstrate understanding of physiologic and psychological responses to surgery​

Participate in rehabilitation process​

​

hemmorrhage

-low BP high heart rate

shock

-BP drop

-WBC increase

when treating an infection

get culture first then get antibiotics

Thrombophlebitis

infiltration

pulmonary embolism

-ambulation, compression devices, ted hose, prophylactic meds (lovonox)

prevent respiratory complications

-elevate HOB

-Incentive spirometer

-cough deep breath

-ambulation (3x a day as per order)

-oral care (q shift and for intubating q4 hrs)

changing surgical dressing

-if you see bleeding circle area and call HCP

-let HCP know dressing has not been changed

-surgeon should do first surgery dressing change

- dressing must stay on for first 24 hours

nutriition

-clear liquid full liquid, advance as tolerated

prevent wound complications

Interventions ​

-Assess vital signs​

-Maintain hydration​

-Maintain nutritional status​

-Proper hygiene​

-Maintaining aseptic technique

Discharge Planning

Teaching​:when and how to take medication and for how long​

Wound care-report temperature or discharge from incision site​

No heavy lifting more than 5 lbs​

Don’t wash with soap just let water run​

Make follow up day of discharge​

Educate s/s to look for​

If on narcotics no driving​

Activity- be mobile walk around and use IS​

Nutrition- eat good diet and take stool softener when on narcotics​

Support systems- family to help or friends may need home health care involved

Thrombophlebitis

Inflammation of veins due to blood clots.