N361 Perioperative narrated (A)

Nursing Management of Perioperative Clients

Perioperative Period

• Definition: The perioperative period encompasses three phases surrounding surgery:

  • Preoperative: Before surgery.

  • Intraoperative: During surgery.

  • Postoperative: After surgery.

Preoperative Nursing Care

• Components:

  • Education of the patient.

  • Interventions to reduce anxiety and complications while promoting cooperation.

• Roles of Nurse:

  • Educator: Providing necessary information.

  • Advocate: Supporting the patient’s needs and decisions.

Types of Surgery

• Diagnostic: Determine or confirm a diagnosis or cell type of ca

• Ablative: Removal of tissue.

• Constructive/Reconstructive: Repairing or reconstructing.

• Palliative: Alleviating symptoms without curing illness.

• Transplant: Replacing damaged organs.

• Cosmetic: Enhancing physical appearance.

Urgency of Surgery

• Elective: Planned, non-emergency.

• Urgent: Requires prompt attention, but not emergencies.

• Emergent: Immediate action is necessary.

Degree of Risk in Surgery

• Minor Surgery: Low risk.

• Major Surgery: Higher risk concerns.

Extent of Surgery

• Simple: Limited procedure.

• Radical: Extensive surgery.

Surgical Settings

• Inpatient: Patient admitted to the hospital.

• Out-patient/Ambulatory: Patient undergoes surgery and returns home on the same day (70-90% of procedures).

Surgical Risk Factors

• Age: Increased risk of complications due to factors like decreased immune function and chronic illness.

• Medical History: Consideration of chronic illnesses, prior cardiac, and pulmonary history.

  • Povidone-iodine: Important for skin preparation; users with shellfish allergies must be cautious.

  • Discharge planning: Ensuring safe post-surgery recovery.

Physical Assessment

• Conduct a thorough assessment including:

  • Vital signs (baseline).

  • Assessment of cardiovascular, respiratory, and renal systems, neurologically as well as psychosocially.

Preoperative Diagnostics

• Essential Tests:

  • Complete blood count, serum electrolytes, fasting blood glucose, coagulation studies, urinalysis.

  • Additional tests: Chest X-ray, Electrocardiograms (for those over 40), blood typing/cross-match, pulmonary function tests, and arterial blood gases.

Nursing Diagnoses

• Common nursing diagnoses for preoperative patients:

  • Anxiety/Fear.

  • Health-seeking behavior.

  • Disturbed sleep patterns.

  • Ineffective coping mechanisms.

  • Anticipatory grieving.

  • Interrupted family processes.

Preoperative Interventions

• Strategy Involves:

  • Review of planned surgery.

  • Obtain comprehensive client history.

  • Conduct complete physical assessment.

  • Administer preadmission treatments and diagnostic tests.

  • Ensure thorough understanding and answer any family and client questions.

  • Discuss discharge plans with the patient and family.

Informed Consent

• Requirement: Must be signed by either the patient or legal guardian.

• Notable Points:

  • In life-threatening situations, consent is desired but not always essential.

  • Separate consents are needed for anesthesia and blood use.

  • Clients can determine directives concerning care in advance.

Elements of Informed Consent

• Key Components:

  1. Voluntary nature of consent.

  2. Comprehensive provision of information.

  3. Comprehension of the information provided.

  4. Competency of individual to make decisions.

Preoperative Preparation

• NPO Guidelines: Generally include fasting for 6-12 hours prior to surgery.

• Medication Consideration: Details on which medications can be administered while the patient is NPO.

• Gastrointestinal Preparation: Critical for abdominal, pelvic, and perianal surgeries which may include bowel evacuation.

• Skin Preparation: Importance of skin cleanliness prior to surgery.

• Diabetic Client Care: Insulin management during NPO period and monitoring hypoglycemia signs.

Chart Review

• Important aspects include:

  • Signatures for surgical permits and allergies noted.

  • Measurements: Height and weight.

  • Report and document abnormal results.

  • Vital signs should be checked 1-2 hours before surgery.

Preoperative Chart Review Components

• Ensuring patient readiness includes:

  • Confirming absence of sensory deficits.

  • Ensuring the patient is in appropriate attire (gown, removed valuables).

  • ID band in place; false teeth, glasses, and contact lenses removed; jewelry secured or taped.

Surgical Team Members

• Roles in Surgical Setting:

  • Surgeon.

  • First Assist.

  • Anesthesiologist and Certified Registered Nurse Anesthetist.

  • Circulating nurse.

  • Scrub nurse.

Types of Anesthesia

• Categories:

  • General: Affects the entire body.

  • Regional: Blocks sensation in a large part of the body.

  • Local: Numbs a small area.

  • Moderate sedation: Calms the patient but allows for continued awareness.

Nursing Diagnoses for Intraoperative Phase

• Common Diagnoses:

  • Impairment of skin integrity.

  • Ineffective airway clearance.

  • Risk for aspiration.

  • Decreased cardiac output.

  • Altered thought processes due to anesthesia.

  • Potential for fluid volume excess/deficit.

  • Risk for injury related to positioning.

Intraoperative Complications

• Potential Complications:

  • Nausea and vomiting.

  • Hypoxia.

  • Hypothermia.

  • Malignant hyperthermia.

Postoperative Phase

• Begins when clients are moved to Post Anesthesia Care Unit (PACU).

• Focus on monitoring:

  • Vital signs.

  • Level of consciousness.

  • Providing emotional support.

  • Assessing hydration and managing pain.

Postoperative Care Steps

• Once the client is stable:

  • Report from PACU nurse to floor nurse.

  • Immediate assessment by floor nurse, including LOC, vital signs, and pain levels.

  • Monitoring IV fluids and drainage tubes.

  • Reassess according to hospital policies and be vigilant for complications.

Postoperative Complications

• Categories of complications include:

  • Respiratory.

  • Circulatory.

  • Gastrointestinal.

  • Genitourinary.

  • Integumentary (skin).

Interventions for Complications

• Atelectasis: Position in semi-Fowler's, administer oxygen, facilitate breathing exercises, ensure hydration, provide emotional support, and administer pain control.

• For Pneumonia: Monitor vital signs, place patient in semi-Fowler’s position, maintain nutritional status, and provide frequent oral care and medication as prescribed.

• Pulmonary Embolism: Notify physician, maintain bed rest, manage fluid intake, oxygen administration, and anticoagulation treatment.

Cardiac Complications - Hemorrhage and Hypovolemic Shock

• For Hemorrhage: Apply pressure, prepare for possible reoperation, maintain airway, and monitor vital signs.

• For Hypovolemic Shock: Keep airway patent, administer oxygen, maintain position, monitor vitals, and provide warm fluids.

Interventions for DVT

• Key interventions:

  • Maintain bed rest.

  • Use TED hose.

  • Elevate affected limb.

  • Administer anticoagulant therapy and apply warm moist heat.

Gastrointestinal Interventions

• For abdominal distention: Assess bowel sounds, encourage mobility, and maintain fluid intake.

• For Nausea and Vomiting: Maintain a clean atmosphere, provide an emesis basin, and administer antiemetic medications.

Paralytic Ileus Management

• Recognize signs such as abdominal pain, distention, and absent bowel sounds.

• Interventions: Use a nasogastric tube, maintain NPO, replace electrolytes, and consider surgery if obstruction persists.

Genitourinary Interventions

• Manage urinary retention with techniques like bladder scanning, I&O measures, and bladder massage.

Integumentary System Interventions

• For Wound infection: Monitor for signs of wound sepsis, maintain aseptic technique, encourage proper nutrition, and administer antibiotics.

• For Wound dehiscence/evisceration: Notify the physician, apply sterile gauze, and ensure bedrest with flexed knees to alleviate abdominal pressure.