Perioperative Nursing Management

PERIOPERATIVE NURSING NOTES

NURS 3277 - MEDICAL-SURGICAL NURSING

OBJECTIVES

• Describe the surgical experience.

• Identify factors that may affect the surgical patient.

• Conduct a nursing history and physical assessment.

• Describe the nursing role of the surgical patient.

• Differentiate between general, regional, and local anesthesia.

• List factors that may affect a postoperative patient in the recovery period.

• Explain the nursing management of potential complications patients face postoperatively.

CHAPTER 14 - PREOPERATIVE NURSING MANAGEMENT

THREE PHASES OF THE PERIOPERATIVE PERIOD

1. Preoperative: The client decides to have surgery and transfers to the operating room (OR).

2. Intraoperative: Care during the surgery, continuing until transfer to the Post Anesthesia Care Unit (PACU).

3. Postoperative: From PACU to the last follow-up visit.

CLASSIFICATION OF SURGICAL PROCEDURES

• Urgency:

  • Elective: Scheduled in advance for non-life-threatening conditions.

  • Urgent: Requires prompt attention but not immediate.

  • Emergency: Requires immediate attention to save life or function.

• Risk:

  • Minor: Low risk of complications.

  • Major: Higher risk of complications and longer recovery time.

• Purpose:

  • Diagnostic: To determine the nature of a disease.

  • Curative: To treat or eliminate the disease.

  • Preventive: To prevent disease or complications.

  • Ablative: To remove tissue or organ.

  • Palliative: To relieve symptoms without curing disease.

  • Reconstructive: To restore function or appearance.

  • Transplantation: To replace a failing organ or tissue.

  • Constructive: To replace missing structures.

PREADMISSION TESTING

• Initiates the nursing assessment process.

• Admission data includes demographics, health history, and other information pertinent to the surgical procedure.

• Verifies completion of preoperative diagnostic testing according to patient’s needs.

• Begins discharge planning by assessing patient’s need for postoperative transportation and care.

PREOPERATIVE ASSESSMENT

Components include:

• Health history and physical exam.

• Medications and allergies (important for managing surgical risk).

• Nutritional and fluid status.

• Dentition (oral health issues affecting anesthesia).

• Drug or alcohol use (can impact anesthesia and recovery).

• Respiratory and cardiovascular status (essential for safe anesthesia).

• Hepatic, renal, endocrine, and immune function.

• Previous medication use.

• Psychosocial factors.

• Spiritual and cultural beliefs (impacting care and consent).

MEDICATIONS THAT POTENTIALLY AFFECT SURGICAL EXPERIENCE

• Corticosteroids: Can alter immune response and wound healing.

• Diuretics: Can cause electrolyte imbalances; must be assessed.

• Phenothiazines and tranquilizers: Impact sedation and perception.

• Insulin: Requires careful management in diabetic patients.

• Antibiotics: Can prevent infection or cause allergic reactions.

• Anticoagulants: Increased bleeding risk; require monitoring.

• Anticonvulsant medications: Important for seizure management.

• Thyroid hormone: Affects metabolic rate and response to anesthesia.

• Opioids: Risk of respiratory depression and nausea/vomiting.

• Over-the-counter and herbal supplements.

GENERAL PREOPERATIVE NURSING INTERVENTIONS

• Psychosocial interventions:

  • Providing emotional support.

  • Reducing anxiety and decreasing fear.

  • Respecting cultural, spiritual, and religious beliefs.

• Maintaining patient safety.

• Managing nutrition and fluid status.

• Preparing bowel and skin (ensuring patient is ready for surgery).

GERONTOLOGIC CONSIDERATIONS

• Older adult patients are at higher risk for complications from anesthesia and surgery due to:

  • Age-related cardiovascular and pulmonary changes.

  • Decreased tissue elasticity in lung and cardiovascular systems.

  • Reduced lean tissue mass affecting recovery.

  • Decrease in liver metabolism rates for anesthetics.

  • Decreased kidney function can slow elimination of waste and anesthetics.

  • Impaired metabolic rate and thermoregulatory mechanisms.

INFORMED CONSENT

• Should be documented in writing before non-emergent surgery; a legal mandate.

• The surgeon must explain the procedure, benefits, risks, and potential complications.

• The nurse clarifies information provided and witnesses the signature.

• Consent is only valid when signed before administering psychoactive premedication.

• Must accompany patient to the OR.

PATIENT EDUCATION

• Importance of deep breathing, coughing, and incentive spirometry.

• Mobility and active body movement.

• Pain management strategies.

• Cognitive coping strategies to reduce anxiety.

• Instructions for patients undergoing ambulatory surgery.

IMMEDIATE PREOPERATIVE NURSING INTERVENTIONS

1. Patient changes into gown.

2. Hair covered, mouth inspected, and jewelry removed.

3. Valuables stored in a secure place.

4. Administering preanesthetic medication.

5. Maintaining the preoperative record.

6. Transporting the patient to the presurgical area.

7. Attending to family needs.

CHAPTER 15 - INTRAOPERATIVE NURSING MANAGEMENT

SURGICAL TEAM ROLES

• Circulating Nurse: Manages the overall environment and care during surgery.

• Scrub Role: Assists with sterile instruments and supplies.

• Surgeon: Conducts the surgical procedure.

• Registered Nurse First Assistant: Assists the surgeon, can be involved in suturing and hemostasis.

• Anesthesiologist or Anesthetist: Manages anesthesia and monitors the patient.

• Importance of the nurse’s role as a patient advocate.

TYPES OF ANESTHESIA

• General Anesthesia: Administered via inhalation or intravenously, resulting in complete unconsciousness.

• Moderate Sedation/Analgesia (Conscious Sedation): For short-term, minimally invasive procedures where the patient remains semi-conscious.

• Regional Anesthesia: Injection of anesthetic near a nerve or along a nerve pathway, anesthetizing specific regions of the body.

• Topical and Local Anesthesia: Applied to mucous membranes, open skin, or wounds.

STATES OF ANESTHESIA

• Loss of consciousness.

• Amnesia (loss of memory).

• Analgesia (pain relief).

• Relaxed skeletal muscles.

• Depressed reflexes.

INTRAOPERATIVE COMPLICATIONS

• Anesthesia Awareness: The rare occurrence of being conscious during surgery.

• Nausea and Vomiting: Common side effects post-anesthesia.

• Anaphylaxis: Severe allergic reaction; risk during any surgical procedure.

• Hypoxia: Insufficient oxygen levels; can lead to respiratory complications.

• Hypothermia: Drop in body temperature during surgery.

• Malignant Hyperthermia: A genetic disorder triggered by certain anesthetics; leads to a hypermetabolic state.

• Infection: Risk during surgical procedures, emphasizing the need for aseptic technique.

ADVERSE EFFECTS OF SURGERY AND ANESTHESIA

• Allergic Reactions: Reactions to anesthetics or medications.

• Drug Toxicity or Reactions: Can occur with certain medications.

• Cardiac Dysrhythmias: Irregular heartbeats during or post-operation.

• CNS Changes: Oversedation or undersedation from anesthesia.

• Trauma: Injury to laryngeal, oral, nerve, skin, including burns.

• Hypotension: Low blood pressure; needs monitoring.

• Thrombosis: Risk increases during and after surgery; preventive measures needed.

GERONTOLOGIC CONSIDERATIONS IN INTRAOPERATIVE CARE

• Older adult patients are at increased risk for complications during surgery, echoing preoperative considerations.

• Factors include age-related physiological changes, reduced clearance rates in the liver and kidneys, and frailer cardiovascular and pulmonary systems.

PREVENTION OF INFECTION

1. Surgical Environment Zones:

   • Unrestricted Zone: Street clothes allowed.

   • Semirestricted Zone: Scrub clothes and caps required.

   • Restricted Zone: Scrub clothes, shoe covers, caps, and masks required.

2. Surgical Asepsis: Following strict hygiene protocols.

3. Environmental Controls: Maintaining a clean surgical environment to reduce infection risk.

NURSING PROCESS: INTERVENTIONS

• Reducing Anxiety: Providing support and education.

• Reducing Latex Exposure: Identifying patients with latex allergies.

• Preventing Perioperative Positioning Injury: Proper positioning to avoid nerve compression or musculoskeletal injury.

• Protecting Patient from Injury: Ensuring safety protocols.

• Serving as Patient Advocate: Ensuring patient rights and preferences are respected.

• Monitoring and Managing Potential Complications: Vigilant assessment during surgery.

PROTECTING THE PATIENT FROM INJURY

• Patient Identification: Ensure proper identification prior to procedures.

• Correct Informed Consent: Verification of consent prior to anesthesia and surgery.

• Verification of Health History and Exam Records: Including allergies.

• Monitoring and Modification of Physical Environment: Safety measures in place during surgery.

• Verification/Accessibility of Blood Products: Ready access if needed.

CHAPTER 16 - POSTOPERATIVE NURSING MANAGEMENT

POSTANESTHESIA CARE UNIT (PACU)

• Phase I: Immediate recovery requiring intensive nursing care; close monitoring of vital signs and responsiveness.

• Phase II: Preparation for transfer from PACU; patient recovering from anesthesia effects and must return to cognitive baseline with stable vital signs.

RESPONSIBILITIES OF THE PACU NURSE

• Review pertinent information and perform a baseline assessment upon the patient's admission.

• Assess:

  • Airway: Ensure it is patent and assess breathing.

  • Level of Consciousness: Monitor responsiveness and cognitive status.

  • Cardiac and Respiratory Status: Vital sign checks and assessment of wound.

  • Wound & Pain assessment.

• Check drainage tubes, monitoring lines, IV fluids.

• Administer postoperative analgesia as indicated.

• Transfer report to another unit or discharge patient to home with appropriate care instructions.

OUTPATIENT SURGERY/DIRECT DISCHARGE

• Discharge planning and assessment: Provide clear written and verbal instructions regarding follow-up care, potential complications, wound care, activity limitations, medications, and dietary restrictions.

• Prescriptions and contact information: Offered to patients and their responsible adult who will accompany them.

• Considerations: Patients are not to drive themselves home due to potential sedation effects on judgment and memory.

NURSING MANAGEMENT OF THE HOSPITALIZED POSTOPERATIVE PATIENT

• Assessment Focus Areas:

  • Respiratory status: Regular monitoring.

  • Pain assessment: Evaluate and manage.

  • Mental Status / Level of Consciousness: Regular checks for confusion.

  • General discomfort reporting and assessment.

MAINTAINING A PATENT AIRWAY

• Primary consideration: Necessary for effective ventilation and oxygenation.

• Actions include:

  • Providing supplemental oxygen as indicated.

  • Assessing breathing by feeling for air movement.

  • Keeping head of bed elevated 15 to 30 degrees unless contraindicated.

  • Suctioning if warranted.

  • Turning the patient to the side in case of vomiting to prevent aspiration.

MAINTAINING CARDIOVASCULAR STABILITY

• Monitor indicators of cardiovascular status: Vital signs and fluid status.

• Assess all IV lines: Check for patency and proper function.

• Potential Complications to Monitor:

  • Hypotension and shock: Watch for hypotensive signs.

  • Hemorrhage potential: Continuous assessment for bleeding.

  • Hypertension and arrhythmias: Maintain vigilance for hemodynamic stability.

INDICATORS OF HYPOVOLEMIC SHOCK/HEMORRHAGE

• Key signs include:

  • Pallor: Paleness of skin.

  • Cool, moist skin: Indicative of shock.

  • Rapid respirations.

  • Cyanosis: Bluish discoloration indicating severe oxygen deficiency.

  • **Rapid, weak, thread pulse.

  • Decreasing pulse pressure: A sign of diminished cardiac output.

  • Low blood pressure: Critical threshold values for intervention.

  • Concentrated urine: Indicative of renal perfusion status.

RELIEVING PAIN AND ANXIETY

• Assess comfort levels: Regularly check for pain.

• Control of environment: Maintain a quiet area with low lights, minimizing stimuli.

• Administer analgesics: Typically short-acting opioids post-surgery.

• Family presence: Address family anxiety and provide updates as necessary.

• Nonpharmacologic support: Methods to help manage emotional and psychological distress.

CONTROLLING NAUSEA AND VOMITING

• Intervention: Act promptly at the first signs of nausea; don’t wait for progression to vomiting.

• Medications: Utilize as necessary based on assessment of postoperative nausea/vomiting risk.

• Evaluative measures: Prophylactic treatment where indicated to minimize postoperative nausea.

WOUND HEALING

• First-Intention Wound Healing: Occurs in primary closure and is the quickest mode of healing.

• Second-Intention Wound Healing: Occurs in more complex wounds requiring granulation and re-epithelization.

• Factors affecting wound healing include:

  • Oxygen levels, blood supply, nutrition, presence of infection, and underlying health conditions.

PURPOSE OF POSTOPERATIVE DRESSINGS

• Create a healing environment.

• Absorb drainage effectively.

• Splint or immobilize the surgical site.

• Protect the wound from external contaminants.

• Promote homeostasis and provide patient comfort.

CHANGING THE POSTOPERATIVE DRESSING

• First dressing change: Can be performed by the nurse, ensuring sterile technique.

• Types of dressing materials: Use appropriate materials for the site and purpose.

• Process includes: Assessment of the wound, proper application of dressing, taping methods, and evaluating patient response.

• Documentation: Each change and observations must be accurately recorded.

NURSING CARE OF THE HOSPITALIZED PATIENT RECOVERING FROM SURGERY

• Comprehensive assessment of physiological status.

• Monitor for complications: Early detection is key for successful management.

• Manage pain: Integral to recovery.

• Implement measures: Achieve long-term health goals collectively.

COLLABORATIVE PROBLEMS

1. Pulmonary infection/hypoxia.

2. Deep vein thrombosis/pulmonary embolism (PE).

3. Hematoma/hemorrhage.

4. Infection.

5. Wound dehiscence or evisceration.

MANAGING POTENTIAL COMPLICATIONS

• Preventive strategies for:

  • VTE/PE: Encouraging movement and assessing risk factors.

  • Hematoma: Monitoring surgical sites closely.

  • Infection: Observing for signs and maintaining sterility.

  • Wound dehiscence and evisceration: Educating patients on care of surgical sites.

INTERVENTIONS: PREVENTING RESPIRATORY COMPLICATIONS

• Regular monitoring of vital signs.

• Implementing deep breathing exercises.

• Encouraging coughing: To clear secretions.

• Promoting incentive spirometry use.

• Turning in bed every 2 hours to promote lung expansion and prevent atelectasis.

• Increasing mobility: As soon as feasible to encourage lung function.

• Maintaining hydration: Important for respiratory function.

• Avoid positioning that decreases ventilation.

• Monitoring responses: To narcotic analgesics to mitigate respiratory depression.