Midterm 217 1-6 week

Pre-Operative Teaching

Exercises:

• Deep Breathing and Coughing:

  • These exercises are critical for preventing respiratory complications, particularly pneumonia, which is a common concern after surgery.

  • Patients should be taught to take deep breaths, hold for a few seconds, and then exhale slowly to aid in lung expansion.

  • Encouragement to practice coughing is also important as it helps clear mucus from the airways postoperatively and facilitates better breathing.

• Incentive Spirometry:

  • This device encourages patients to take deep breaths by providing visual feedback on their breathing efforts.

  • Preoperative education should include instruction on how to use the spirometer effectively.

  • Patients should be advised to continue utilizing the spirometer after surgery to maintain lung expansion, reduce the risk of atelectasis, and promote overall respiratory function.

• Leg Exercises:

  • Simple leg exercises such as ankle pumps, flexing, and pointing toes play a significant role in promoting blood circulation.

  • Engaging in these exercises can significantly reduce the risk of developing deep vein thrombosis (DVT).

  • Demonstration and encouragement of these exercises should be integrated into the pre-op teaching process to emphasize their importance.

• Early Ambulation:

  • Informing patients about the benefits of early ambulation post-surgery is crucial.

  • Early movement aids in circulating blood, promotes lung expansion by enhancing oxygenation, and stimulates gastrointestinal motility to help prevent postoperative ileus.

NPO (Nil Per Os):

• It is standard practice for patients to fast for 6-12 hours before surgery.

• This fasting period is essential for preventing aspiration during anesthesia administration.

• Nurses and healthcare providers must clearly explain this requirement to the patients, reassuring them that it is necessary for their safety.

• Addressing any patient queries regarding specific fasting durations and what can or cannot be consumed before surgery is equally important.

Pre-Op Care in the Holding Area

• Vitals and Verification:

  • Before surgery, confirming the patient's identity, surgical site, and procedure is critical.

  • This is part of the standard “time-out” protocol aimed at prioritizing accuracy and patient safety.

  • Recording baseline vital signs, including blood pressure, heart rate, temperature, and oxygen saturation, helps assess the patient's preoperative status and identify any immediate concerns.

• IV Line Setup:

  • Establishing intravenous (IV) access is crucial for administering preoperative medications, fluids, and necessary antibiotics.

  • Nurses should ensure that the IV line is patent and functioning properly before the surgical procedure to avoid delays.

• Patient Comfort and Anxiety Reduction:

  • Many patients experience anxiety before surgery.

  • Providing reassurance and answering any questions can significantly ease their anxiety.

  • Creating a calming environment and demonstrating empathy is vital in addressing patient concerns.

  • In some circumstances, anxiolytic medication (like a benzodiazepine) may be administered to help patients relax before surgery.

Pre-Op Assessment

• Use of Herbal Supplements:

  • It is important to inform patients that certain herbal supplements may negatively interact with anesthesia or increase the risk of bleeding during and after surgery.

  • Common supplements of concern include garlic, ginger, and ginkgo biloba, which are known to enhance bleeding risk.

  • St. John’s Wort can affect how anesthesia is metabolized and cleared from the body, besides other herbs like echinacea and kava, which can influence liver function and anesthetic metabolism.

• Lab Tests:

  • Typical preoperative laboratory tests typically include a Complete Blood Count (CBC) to assess hemoglobin, hematocrit, and platelet levels.

  • Coagulation studies (PT, INR, aPTT) are essential for patients on anticoagulants to evaluate bleeding risk effectively.

  • An electrolyte panel is also used to obtain baseline levels for patients since imbalances can affect anesthesia and recovery outcomes.

  • Blood glucose levels are crucial for diabetic patients to monitor closely to prevent perioperative hypoglycemia or hyperglycemia.

• Allergies:

  • A thorough verification of medication allergies, particularly to antibiotics, anesthetic agents, and other allergens (like latex), should be conducted to implement necessary precautions.

  • This is critical for allowing the surgical team to ensure that alternative medications or anesthetic agents are available if needed during surgery.

Purpose of Pre-Op Assessment

• The preoperative assessment plays an essential role in identifying any pre-existing conditions that could affect the surgical procedure or anesthesia administration.

• It allows healthcare providers to establish baseline data and identify specific areas of risk and informs perioperative planning, ensuring safe and individualized patient care.

Definitions of Surgery Types

• Emergency Surgery:

  • This type of surgery must be performed immediately to save a life or preserve essential biological function.

  • Typical examples include cases of trauma or a ruptured appendix.

  • Emergency surgeries typically involve minimal preoperative preparation due to their urgent nature.

• Elective Surgery:

  • This is a planned surgery that is non-emergency and can be scheduled at the patient’s convenience.

  • Elective surgeries allow for adequate time for thorough preoperative assessments and interventions to ensure patient safety.

• Urgent Surgery:

  • Surgery classified as urgent is needed within a short timeframe (usually within 24-48 hours) to prevent serious complications.

  • An example is surgery required to treat an infection or repair a fracture promptly.

• Major Surgery:

  • Represents invasive procedures that are often lengthy and carry a higher risk of complications.

  • Examples of major surgeries include operations on the heart or brain, which require extensive preoperative and postoperative planning, monitoring, and care.

Key Medications to Consider Preoperatively

• Warfarin:

  • As an anticoagulant, warfarin significantly increases bleeding risk during surgery.

  • It is crucial that this medication is typically discontinued several days prior to the procedure, with close monitoring of INR levels to avoid excessive bleeding during and after surgery.

• Insulin:

  • For diabetic patients, adjusting insulin doses is essential due to NPO status, as fasting may induce hypoglycemia.

  • Healthcare providers will often monitor baseline glucose levels and may utilize a sliding scale to manage insulin administration effectively.

• Benzodiazepines:

  • Frequently used for sedation and anxiety reduction preoperatively.

  • The effects on respiratory function must be closely monitored, especially when combined with anesthetics, due to the risk of respiratory depression during and after surgery.

Anesthesia

• Routes of Administration:

  • Anesthesia can be administered via intravenous (IV) routes for a rapid onset, typically used for induction or short surgical procedures.

  • Inhalation is generally used for the maintenance of anesthesia over longer periods, allowing for controlled depth of sedation through gases or volatile agents.

Informed Consent

• Informed consent is a legal and ethical obligation where patients must fully understand the surgery they will undergo, including the associated risks, benefits, and alternatives.

• Patients’ voluntary consent to proceed is mandatory, with healthcare staff fulfilling their responsibilities to ensure that patients are thoroughly informed before proceeding.

Advance Directives

• Advance directives are crucial legal documents that detail a patient's healthcare preferences in the event they become incapacitated.

• These documents may include Do Not Resuscitate (DNR) orders and living wills.

• Such directives help guide the healthcare team in making decisions that align with the patient's wishes and healthcare goals.

Post-Operative Care

• Effects on the Gastrointestinal (GI) and Urinary Systems:

  • Postoperative ileus is a temporary condition characterized by decreased bowel activity and is common after surgery.

  • Assessment of bowel sounds, monitoring for abdominal distension, and gradually reintroducing food are critical components of postoperative care.

  • Additionally, signs of nausea and vomiting (potential side effects of anesthesia) need to be vigilantly monitored to ensure patient comfort.

• Urinary System:

  • Low urinary output can indicate dehydration, shock, or possible kidney complications.

  • Close monitoring of urinary output is vital, alongside encouraging appropriate fluid intake post-surgery as deemed necessary.

• Fluid and Electrolyte Imbalances:

  • Postoperative patients are at an increased risk for fluid and electrolyte imbalances due to fluid shifts, blood loss, and IV fluid administration after surgery.

  • Monitoring lab values, assessing intake and output, and watching for signs of dehydration or fluid overload is essential to manage these risks effectively.

• Respiratory System:

  • To prevent complications like atelectasis and pneumonia, patients should be motivated to use incentive spirometry, perform deep breathing exercises, and ambulate early post-surgery.

  • Healthcare staff should regularly assess for cough and clear lung sounds to ensure effective airway clearance and optimal respiratory function.

• Cardiovascular System:

  • Hypotension in the postoperative period may indicate blood or fluid loss or anesthetic-related effects.

  • Monitoring blood pressure allows for timely intervention, such as administering fluids or medications as needed.

  • Implementing preventive measures against DVT through the use of compression devices, encouraging leg exercises, and early mobility is crucial in postoperative care.

• Physiological Responses:

  • Pain management is crucial in the postoperative setting.

  • Administration of analgesics as ordered and monitoring for adverse effects is vital to ensure effective pain control.

  • Additionally, monitoring for temperature fluctuations can indicate potential infections or hypothermia related to anesthesia.

  • Appropriate interventions, such as providing warming blankets or antipyretics, should be deployed as necessary to maintain patient comfort and safety.

• Neurological Changes:

  • Postoperative emergence delirium can result in confusion, agitation, or disorientation, particularly in elderly patients.

  • Continuous monitoring of the patient’s mental status is critical, and creating a calm, quiet environment can help facilitate recovery and mitigate the symptoms of delirium.