Perioperative Nursing Flashcards

Surgical Nursing

It is the nurse's responsibility to be attentive and active in providing safety in all phases of the perioperative experience. The nursing process and clinical judgment models are the tools that nurses apply to ensure individualized and family-centered strategies are utilized throughout the experience to support an injury-free and holistic perioperative period.

EDNX Item Container

Key elements for surgical safety and patient care include:

• Antibiotics per protocol
• Pressure point padding
• Maintain sterile technique
• Personal Protective Equipment (PPE)
• Surgical "time-out" to verify patient and procedure
• Continuous patient monitoring
• Instrument and sponge count

Surgical Risk Factors

Surgical risk factors affecting patients at any phase in the perioperative experience:

• Smoking
• Age: Individuals at each end of the age spectrum are at higher risk during surgery due to immature or aging immune systems, inability to regulate body temperature, and fragile skin.
• Nutrition
• Obesity
• Obstructive sleep apnea (OSA)
• Immunosuppression
• Fluid and electrolyte imbalance
• Postoperative nausea and vomiting (PONV)
• Venous thromboembolism (VTE)

Preoperative Surgical Phase: Nursing Process and Assessment

• Medications (Table 50.5): Inpatient vs outpatient. Some medications may be discontinued before surgery.
• Allergies: Medications, topical agents, latex, food.
• Smoking habits
• Alcohol ingestion and substance use and abuse
• Pregnancy: Females of childbearing age will need to have a pregnancy test before surgery; if positive, the surgery may be delayed or canceled.
• Perceptions and knowledge regarding surgery
• Culture may impact if their provider can be male or female. They may have special food requests for their recovery phase.
• Gender
• Labs/diagnostics: Review all lab work and ensure that anesthesia has reviewed it as well. Results of certain labs, such as platelets and bleeding items, may delay surgery if they are not within the normal limits.
• Communication: It is important to advocate for the patient and communicate how they currently feel and if there have been any changes over the last 24 hours.

Begins with the decision to have surgery and lasts until transfer to the operating suite. The nurse assesses the individual to establish a baseline status by which changes in condition and risks to health can be evaluated. Ensure that a thorough medical history has been completed well in advance of surgery.

Preoperative Instructions and Family Involvement

• Before the day of surgery, the client will identify family members with whom the nurses and surgeon can share information.
• Nurses will review preoperative instructions such as physical preparation for surgery and expectations. In the preoperative area, the nurse will review instructions and exercises for the postoperative period.
• The family can assist the client in promoting a healthy recovery and preventing complications. If the client is a minor, the family plays a central role in education and support.

Preoperative Surgical Phase: Implementation

Acute Care

• Minimizing risk for surgical wound infection
  • Antibiotics
  • Skin antisepsis
  • Clipping instead of shaving hair
• Maintaining normal fluid and electrolyte balance
  • Fasting before surgery
  • IV fluid replacement
  • Parenteral nutrition
• Preventing bowel incontinence and contamination
  • Bowel preparations

Preparation on the Day of Surgery

• Hygiene
• Preparation of hair and removal of cosmetics
• Removal of prostheses
• Safeguarding valuables
• Preparing the bowel and bladder
• Vital signs
• Prevention of DVT: Anti-embolism devices
• Administering preoperative medications
• Documentation and hand-off
• Eliminating wrong site and wrong procedure surgery

Pre-Op Checklist: Day of Surgery

• Preoperative education completed
• Informed consent signed
• NPO - Bowel prep
• Skin prep - Shower or bath in anti-microbial soap
• Documentation / Checklist of valuables
• Voided prior to transfer
• Pre-op meds - Given and charted
• Side rails after pre-op, bed in low position
• Hospital gown
• Allergy band
• ID band
• Dentures, eyeglasses, hearing aids, contacts - Left in place or removed
• Makeup and nail polish removed
• Vital signs before transfer
• Pre-op lab work on chart. Surgeon notified of abnormal values
• Medications history. MAR on chart. EHR/EMR up-to-date. High alert meds noted

Intraoperative Phase

Extends from admission to the surgical department to transfer to the postanesthesia care unit (PACU).

• Circulating nurse: Observes environment for hazards, does not scrub in. Manages patient positioning, antimicrobial skin prep, meds, implants, placement & function of IPC devices, specimens, warming devices, surgical counts of instruments & dressings.
• Scrub nurse: Assists with surgical procedure. Ability to anticipate each instrument & supply needed by the surgeons.
• When the client leaves for the operating room suite, the family is taken to the waiting room. Once in the operating room suite, it is the circulating operating room nurses job to call the waiting room and update the family on the progress of the surgery.

Postoperative Phase

The postanesthesia care unit (PACU) phase begins with transport to the PACU and continues with recovery, which can be a long-term recovery

Detailed information reported to PACU RN:

• Unusual happenings (malignant hyperthermia)
• Anesthesia
• Vials
• Body system review
• Reactions
• Drains
• Dressings
• IV Fluid
• Medications
• Urine output
• Airway
• Oxygenation

At the end of the surgery, the surgeon will talk with the family in the waiting room. The family will not see the client in the postanesthesia care unit (PACU) but will be kept aware of updates. Once the client is stable and transferred to a room or ready for discharge, the family can see the client. Often, discharge teaching will be reinforced with the family present so they can support their family member at home.

Safety

• Education: The nurse should understand a patient’s and family’s knowledge and expectations (after discharge). The knowledge deficit provides individualized teaching and emotional support measures.
• Identification of the Individual: The surgical team needs to use two patient identifiers to improve the reliability of the patient identification process and decrease the chance of performing the wrong procedure on the wrong patient.
• Wrong Surgery or Wrong Site Prevention: Verifying the correct surgical procedure and the site is the responsibility of the surgical team members. The site should be clearly marked with a permanent marker preoperatively.
• Time-Out: A “time-out” is conducted, right before incision, as a final confirmation of the correct client, procedure, site, and implants.
• Preoperative Checklist: The checklist helps nurses identify specific items that could negatively affect the patient along with verifying the patient is ready for surgery. Items include review of medical history, signed history and physical, lab work, provider orders, removal of metals, consents, allergies confirmed, ID bands placed, and nothing-by-mouth (NPO) status of the patient.
• Inclusion of Family: The nurse should include the family per the patient's wishes. Parents and guardians need to be involved in the preoperative stage if the patient is a minor.
• Consent for Surgery: The nurse will verify the signature on the informed consent for surgery after the surgeon and anesthesiologist talks with the patient. This is part of the preoperative checklist.
• Living Will: This advanced directive gives the provider permission to make medical and end-of-life decisions.
• Power of Attorney: This advanced directive gives a person designated by the patient permission to make medical and end-of-life decisions.
• Organ Donation Legal Considerations: It should be documented whether the client is an organ donor.

Informed Consent

• Signed by physician and anesthesiologist to indicate all risks of surgery and anesthesia fully explained to patient
• Must have date and time correlating with signature
• Must be signed prior to administration of narcotics or any mind-altering medication
• The UCLA Health consent form outlines various aspects of consent, including agreement to the procedure, risks involved, alternatives, and use of specimens for research

Communication and Continuity of Care

Continuity of care is pertinent when caring for surgical clients. Based on the delivery of care model utilized in the perioperative setting, some nurses may follow clients through the preoperative and intraoperative phases of surgery.

In some instances, perioperative nurses follow clients through the postanesthesia care unit (PACU), assessing a client’s health status before surgery, identifying specific client needs, teaching and counseling, preparing for the operating room (OR), and following a client’s recovery.

Different nurses and other healthcare providers also care for a client during each phase of the surgical experience. A smooth communication—“hand-off”—between caregivers is needed to ensure continuity of care and reduce the risk of medical errors.

ISBAR Communication Tool

• I: Identify
  • Identify yourself (name, position, location, and client name)
• S: Situation
  • Describe the patient’s problem and type of surgery
• B: Background
  • Report the patient's background and history
• A: Assessment
  • Provide assessment data
• R: Recommendations
  • Provide recommendations and Interventions that need to be Implemented