Peri Op

Perioperative Nursing Overview

Reasons for Surgery

  • Obstruction: Blockage preventing normal function.

  • Perforation: A rupture that causes leakage of bodily fluids.

  • Infection: Removal of infected tissue or abscess.

  • Tumors: Removal of neoplastic growths.

  • Diagnosis: Surgical procedures can help determine health issues.

  • Palliation: Reducing symptoms without curing the disease.

  • Cosmetic: Enhancements for aesthetic purposes.

  • Cesarean Birth: Surgical intervention during childbirth.

Surgical Classification by Timing

  • Elective: Scheduled at patient and surgeon's convenience.

  • Urgent: Needs to be performed in 24-48 hours.

  • Emergent: Immediate surgery required to prevent death.

Surgical Classification by Context

  • Inpatient: Overnight stay required in a hospital.

  • Outpatient/Ambulatory: Patients return home the same day.

Surgical Considerations

Urgency of Surgery

  • Elective: Planned when the schedule allows.

  • Urgent: Requires prompt intervention within 24-48 hours.

  • Emergent: Necessary to prevent death or serious harm.

Degree of Surgical Risk

  • Minor vs Major: Compares less invasive to highly invasive surgeries.

Extent of Surgery

  • Simple vs Radical: Simple procedures affect a localized area, while radical procedures involve greater anatomical involvement.

Perioperative Patient Care Phases

  • Before Surgery (Preoperative): Assessment and preparation.

  • During Surgery (Intraoperative): Participation and management.

  • After Surgery (Postoperative): Monitoring and care in PACU (Post Anesthesia Care Unit), recovery unit, or home.

Preoperative Nursing Responsibilities

Patient Assessment

  • Medical History: Disclose allergies, past surgeries, chronic conditions.

  • Medications: Review anticoagulants, NSAIDs, steroids, and other pertinent drugs.

Physical Assessment Identifying Risks

  • General: Age, pain status (acute/chronic), nutritional status, and hydration.

  • Systems Review: Circulatory, renal, endocrine, mental health, etc.

Laboratory and Diagnostic Tests

  • Urine Analysis (UA): Assess kidney function and other issues.

  • Comprehensive Metabolic Panel (CMP): Electrolytes, liver function, etc.

  • Complete Blood Count (CBC): Evaluate overall health and detect diseases.

  • Clotting Profile: PT, PTT, INR to assess bleeding risk.

  • Blood Type & Cross Match: Essential for potential transfusions.

  • Pregnancy Test: Important for female patients of childbearing age.

Psychosocial Assessment

  • Cognitive Function: Assess understanding and competence.

  • Anxiety: Evaluate its impact on the patient.

  • Financial Implications: Understand patient responsibilities and support systems.

Signs and Symptoms of Anxiety

  • Physical Indicators: Restlessness, agitation, fearfulness, distraction, crying, uncooperativeness.

Interventions for Anxiety

  • Active Listening and Positive Regard

  • Therapeutic Techniques: Music, imagery, distraction, humor, teaching.

  • Medication Administration: Pre-operative medications as necessary.

Cultural Influences on Surgery

  • Patient Roles: Active versus passive engagement in their care.

  • Family's Role: Importance of family in decision-making and support.

  • Dietary Preferences: Warm versus cold food considerations post-surgery.

  • Perceptions of Surgery: Some may prefer alternative methods over Western surgical practices.

Family Considerations in Care

  • Communication Needs: Address cultural and linguistic barriers.

  • Family Education: Teaching about discharge planning, altered roles, and supportive measures post-surgery.

  • Implementation of Mobility Aids: Use of Incentive Spirometry (IS) for respiratory support, support with ambulation, and fulfilling non-medical needs.

Nursing Diagnoses

  • Common Diagnoses:

    • Fear

    • Deficient Knowledge

    • Anxiety

    • Disturbed Sleep Pattern

    • Anticipatory Grieving

    • Ineffective Coping

Informed Consent: Legal and Ethical Considerations

  • Documentation Requirements: Must be signed by the patient or legal guardian; needs witnessing by an individual of sound mind, not under medication influence.

  • Clarity: No initials or abbreviations on consent forms.

  • Roles: Nurse provides information about the procedure; surgeon describes risks and benefits.

  • Emergency Situations: Requires two physicians or two RNs as witnesses via telephone.

Patient Education Interventions

  • Breathing Exercises: Coughing and deep breathing, splinting, using Incentive Spirometry.

  • Postoperative Mobility: Early ambulation with physical therapy (PT), occupational therapy (OT).

  • Managing Drains/Tubes: Education on managing surgical drains and recognizing signs of infection at the wound site.

  • Pain Management: Techniques and medications.

Immediate Pre-operative Preparation

  • Pre-operative Actions: Scrubbing, bowel preparation, managing IV fluid intake, vital signs checks.

  • Patient Preparation: Removing personal belongings (glasses, jewelry, cosmetics).

  • Patient Safety Measures: Urinary catheterization, confirming patient identity with ID bands.

Preoperative Checklist

  • Documentation Checks: Last intake, blood glucose, vital signs, allergy bands, and lab results.

  • H&P (History & Physical): Required documentation for surgical readiness.

Intraoperative Care Environment

Operating Room Areas

  • Unrestricted Area: Where personnel can enter freely.

  • Semi-restricted Area: Where only authorized personnel can enter; often requires masks and proper attire.

  • Restricted Area: Sterile environment for surgical procedures.

Pre-Operative Holding Area

  • Nursing Duties: Confirm patient identity, ensure documentation accuracy, providing pre-operative education, and emotional support.

  • Interactions: Meetings with anesthetists, CRNAs, and surgeons to discuss the procedure.

Intraoperative Team Composition

  • Roles in the OR:

    • Circulating RN: Oversees patient care and assists in logistics.

    • Scrub Nurse: Maintains sterile field and assists the surgeon directly.

    • Anesthesiologists/CRNA: Manage anesthesia and monitor patient vitals.

    • Surgeon & Assistants: Perform the surgical procedure and provide assistance.

Circulating Nurse Tasks

  • Time Out Protocol: Ensures correctness of patient, site, and procedure.

  • Monitoring OR Traffic: Coordinates personnel within the sterile field.

  • Equipment Management: Ensures safe handling of instruments, maintaining sterile conditions.

  • Patient Safety: Notifies of any safety issues during the process, monitors blood loss and urine output.

Surgical Asepsis Practices

  • Sterile Procedures: Clean environment, proper scrubbing techniques, gowning, and gloving protocols.

  • Observing Sterile Fields: No turning back on sterile fields and maintaining awareness of movements in the OR.

Evidence-Based Safety Practices

  • Joint Commission Universal Protocol: Mandates verification procedures prior to surgery to improve patient safety, including site marking and timeouts.

Hand Hygiene Protocols

  • Guidelines from the CDC: Procedures to ensure effective handwashing and infection prevention.

  • Goals: Improve overall hygiene standards in clinical settings.

Surgical Care Improvement Projects (SCIP)

  • Core Measure Set: Includes prophylactic antibiotic use, blood glucose management, urinary catheter precautions, temperature management, and appropriate hair removal to reduce complications.

Anesthesia Overview

What is Anesthesia?

  • Definition: An induced state of loss of sensation with or without loss of consciousness.

Types of Anesthesia

  • General Anesthesia: Administered as inhalation or intravenous methods.

  • Regional Anesthesia: Includes nerve block and spinal blocks (subarachnoid or epidural).

  • Local Anesthesia: Administered subcutaneously or topically.

  • Monitored Anesthesia Care (MAC): Formerly known as conscious sedation.

Factors Influencing Anesthesia Decisions

  • Surgical Type: Determines the method and medications used.

  • Patient Considerations: Body area involved, position, past reactions, chronic conditions, and adherence to instructions.

Complications Associated with Anesthesia/Surgery

  • Malignant Hyperthermia: Rare but potentially fatal; marked by increased calcium levels in skeletal muscle.

    • Symptoms: Increased body temperature, muscle rigidity, rapid heart rate, respiratory alterations.

    • Management: Immediate cessation of triggering agents, ventilation, cooling measures, and administration of dantrolene.

  • Allergic Reactions: Possible adverse effects from anesthetic agents.

  • Surgical Overdose: Overmedication leading to suppression of vital systems.

Recognition of Malignant Hyperthermia

  • Signs: Rising ETCO2, body rigidity, tachycardia, hypercarbia, and low blood oxygen levels.

  • Immediate Actions: Administer dantrolene, ventilate, and cool patient.

Positioning Considerations

  • Positions During Surgery: Varied positions (supine, Trendelenburg, etc.) affect surgical access and anesthetic management.

Return to Consciousness

  • Considerations Post-Anesthesia: Risk of irritability, restlessness, and confusion; safety measures include padded rails and monitoring.

Post-Operative Nursing Responsibilities

Patient Monitoring in PACU

  • Parameters to Monitor: Airway patency, circulation, vital signs, skin condition, and intake/output status.

Aldrete Scoring System

  • Criteria for Transfer: Patients must score greater than 8 on this scale including activity level, respiration success, and circulation stability.

Common Nursing Diagnoses Post-Operatively

  • Impaired Gas Exchange: Related to potential issues such as alveolar collapse.

  • Risk for Aspiration: Likelihood of foreign material entering the lungs due to anesthetic effects on the gag reflex.

  • Wound Integrity Concerns: Impairments dependent on physical assessments and early detection of deficiencies.

Post-Operative Complications

Categories of Complications

  • Neurologic: Risks stemmed from direct trauma or reduced oxygenation.

  • Cardiovascular: Includes shock or thromboembolic events, namely DVT.

  • Pulmonary Issues: Atelectasis and risk for pulmonary embolism.

  • Gastrointestinal Distress: Nausea, vomiting, and potential ileus.

  • Immunologic Complications: Possible infection post-surgery.

Renal Function Considerations

  • Hormonal Changes: Surgery stimulates ADH production leading to fluid retention and urinary alterations.

Interdisciplinary Collaboration

Key Team Members

  • Family Leaders: Assessing home care safety and evaluating support systems.

  • Planners and Social Workers: Coordinating discharge and home health services.

  • Support Resources: Educating on home care procedures and financial considerations.

Documentation Standards

  • Preoperative Records: Ensuring teaching effectiveness and preparation completeness.

  • Intraoperative Documentation: Complete OR records to maintain patient safety and trace interventions.

  • Postoperative Assessment Records: Observations regarding patient recovery, site assessments, and involvement of interdisciplinary teams.

Patient Case Study Example

  • Patient Profile: Tom, a 40-year-old with a history of smoking, diabetes, and sleep apnea, weighing 340 lbs undergoing bowel resection. Vital signs indicate hypertension, tachycardia, and elevated respiratory rate upon admission.