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NUR 1410 Foundations of Nursing Unit 6: Management of the Perioperative Experience

Perioperative Nursing

  • Definition: Care of patients during the surgical experience which involves three distinct phases:

    • Pre-operative: Before surgery

    • Intra-operative: During surgery

    • Post-operative: After surgery

  • Association of Peri-Operative Registered Nurses (AORN):

    • Sets standards to guide perioperative nursing practice.

Surgical Procedure Suffixes

  • Suffixes used in surgical terminology:

    • -ectomy: Excision of a body part

    • -lysis: Destruction of tissue

    • -orrhaphy: Repair or suture of a part

    • -oscopy: Looking into a body cavity

    • -ostomy: Creation of an opening from an internal organ to the outside

    • -otomy: Cutting into, or incision of a body part

    • -plasty: Repair or reconstruction of a body part

Preoperative Care: Classification of Surgeries

  • Surgical procedures can be classified in several ways:

    • By Body System: Categorizing surgeries based on the system under treatment.

    • By Purpose:

    • Elective: Preplanned, scheduled in advance

    • Urgent: Usually performed within 24-48 hours

    • Emergency: Performed immediately to preserve life

    • By Degree of Risk:

    • Major: High risk procedures

    • Minor: Low risk procedures

Preoperative Care: Patient Assessment

  • Critical preoperative patient assessment to identify risk factors includes:

    • Age

    • Type of surgery

    • Preexisting conditions

    • Cognitive status and learning ability

    • Medications:

    • Prescribed and non-prescribed medications

    • Over-the-counter (OTC) supplements/herbals

    • Personal habits: Exercise, diet, etc.

    • Allergies

Perioperative Care: Surgical Settings

  • Types of surgical settings:

    • Inpatient

    • Outpatient/Ambulatory

  • Determinants include:

    • Complexity of surgery

    • Potential complications

    • General health status of the patient

Pre-operative Nursing Care Goals

  • Establish baseline data regarding:

    • Medical conditions (co-morbidities)

    • Surgical history

    • Identify risk factors

    • Plan care to ensure patient safety and teaching

  • Nursing Assessment consists of:

    • Health History

    • Psychosocial Assessment

    • Physical Assessment

Preoperative Nursing Assessment Categories

  • Physical Assessment:

    • General Health Survey including nutritional status

    • Cardiovascular system

    • Respiratory system

    • Genitourinary system

    • Fluid and electrolyte status

    • Hepatic & renal system

    • Integumentary system

    • Musculoskeletal system

    • Endocrine system

    • Immune system

  • Psychosocial Assessment:

    • Support systems

    • Home environment evaluations

    • Employment status (working outside the home vs at home; retired; unemployed)

    • Dependents

    • Important cultural and spiritual information

    • Level of anxiety and fears

Preoperative Nursing Assessment: Diagnostic Tests

  • Recommended diagnostic tests include:

    • Complete Blood Count (CBC):

    • Includes RBC (Hemoglobin (Hgb) / Hematocrit (Hct)), WBC (Platelets, Neutrophils, etc.)

    • Blood Type: Type and crossmatch

    • Blood Urea Nitrogen (BUN) and Creatinine (Cr)

    • Electrolytes: Important levels to assess

    • Glucose

    • Coagulation tests: Prothrombin Time (PT), Partial Thromboplastin Time (PTT), International Normalized Ratio (INR)

    • Liver Enzymes:

    • Includes ALT, AST, LDH, bilirubin, albumin, and protein

    • Urinalysis (UA)

    • Chest x-ray

    • Electrocardiography (ECG)

Preoperative Care: Knowledge Deficit Goals

  • Goals for preoperative care include:

    1. Patient will not experience post-operative complications

    2. Patient will manage pain and anxiety satisfactorily

  • Pre-procedure requirements include:

    • Provide surgery-specific information

    • Explain postoperative information

    • Demonstrate cough and deep breathing techniques, using an Incentive Spirometer (Triflow)

    • Discuss activity levels, splinting, turning, leg exercises, ambulation

    • Explain equipment used

    • Outline pain management strategies, including medications and splinting

    • Describe progression of nutritional intake (ice, clear liquid, soft, regular)

    • Offer visitor/caregiver information

Prior to Surgery: Legal Preparation

  • Informed Consent for Surgery:

    • Legal and professional requirements include:

    • Description of procedure

    • Name of who will perform the procedure

    • Expected outcome

    • Explanation of risks

    • Voluntary agreement and right to refuse surgery

    • Signatures of patient and witness

    • Responsibility for informed consent lies with the surgeon, who ensures effective communication with the patient.

    • After signing, consent becomes part of the patient’s medical record and travels with the patient to the operating room (OR).

  • Advance Directives:

    • Legal document outlining specific treatment wishes

    • May include Do Not Resuscitate (DNR) or Allow Natural Death preferences

    • Allows the patient to appoint someone (Durable Power of Attorney) to advocate for them if they cannot communicate their wishes.

Case Study: Patient Mr. Egan

  • Patient Information:

    • Name: John Egan

    • Age: 53

    • History: Type I diabetes mellitus, cigarette smoking (1 pack/day), coronary artery disease (CAD), peripheral vascular disease (PVD).

    • Recent history: Wound on left heel measuring 4cm x 2cm developed into potentially life-threatening gangrene infection despite IV antibiotics and debridement.

  • Surgery Scheduled: Below the knee amputation (BKA) of the left lower extremity at 1000 hours tomorrow.

  • Home Medications:

    • Daily insulin, aspirin 325mg/day

  • Allergies: No known drug allergies (NKDA)

  • Support: His wife is accompanying him and an advanced directive is on file at the facility.

Pre-operative Diagnostic Testing for Mr. Egan

  • Considerations include ensuring informed consent, completing pre-operative preparation orders, and performing pre-operative teaching.

  • Maintenance of defined limits (WDL) for glucose levels and providing psychological comfort are priorities.

Observations During Medication Reconciliation for Mr. Egan

  • Concern arises from prescriptions including:

    • Insulin 6 units Regular

    • 15 units Lantus (Glargine) subcutaneously every night

    • Aspirin 325mg by mouth daily

    • Cilostazol 100mg orally twice a day (vasodilator, antiplatelet)

    • Lorazepam 0.5mg IVP on call to OR in the morning (benzodiazepine, antianxiety)

Addressing Psychological Comfort of Mr. Egan

  • Address concerns by engaging in active listening, providing reassurance, and discussing fears about losing a foot and leg.

Nursing Responsibilities: Immediate Pre-operative Checklist

  • Ensure the following before surgery:

    • Review diagnostic test results

    • Accurate identification of patient, procedure, and site

    • Administer preoperative medication

    • Take vital signs

    • Ensure removal of jewelry, contacts, and dentures

    • Address last void or conduct catheterization

    • Send necessary equipment (anti-embolism stocking, pre-op antibiotics) with patient

    • Verify informed consent, complete OR checklist, ID band, patient allergies, and NPO status.

Intraoperative Care: Types of Anesthesia

  • General Anesthesia: Loss of consciousness, analgesia, muscle relaxation, and reflex loss

  • Moderate to Deep Sedation: Administration of IV sedation and analgesia without inducing unconsciousness

  • Regional Anesthesia: Interrupts nerve impulses via methods like peripheral nerve blocks, spinal anesthesia, or epidural anesthesia

  • Local Anesthesia: Injection of an anesthetic agent in a specific area to achieve localized loss of sensation

Intraoperative Phase: Nursing Role in Safety

  • Responsibilities during the intraoperative phase include:

    • Conducting a “time out” for verification of correct patient, procedure, and site

    • Performing equipment/supply counts (sponges, sharps, instruments)

    • Ensuring proper positioning of the patient and maintenance of airway

    • Preventing injury, including grounding pad placement

    • Documenting intake and output, and procurement of specimens

Surgical Sentinel Events: “Never Events”

  • Definition: Errors resulting in serious injury or death which should never occur.

  • Important Note: Medicare will not reimburse for care related to Never Events.

  • Examples include:

    • Surgery on the wrong body part

    • Surgery on the wrong patient

    • Wrong surgery on the right patient

    • Foreign body left inside a patient

    • Surgical site infections

Postoperative Care in the Post Anesthesia Care Unit (PACU)

  • Nursing Assessment must cover the following areas:

    • Respiratory: Airway patency

    • Cardiovascular: Blood pressure comparison with baseline, monitoring for medications, volume overload, or dehydration

    • Central Nervous System (CNS): Level of consciousness (LOC), orientation

    • Integumentary: Skin temperature, color, and condition

    • Wound Status: Assessing surgical site and dressing integrity

    • Fluid Status: Monitoring intake, output, and fluid loss

    • Pain Management: Implement and monitor strategies

  • Assessments must be aggressive, frequent, and comprehensive.

  • Indicators of recovery from anesthesia include patient’s ability to maintain airway independently, stable vital signs, and normal movement/sensation in extremities.

Patient Case: Mr. Egan Post-operatively

  • After surgery, Mr. Egan goes to the PACU where he is extubated and begins to recover. Key observations for Mr. Egan include:

    • Estimated blood loss (EBL): 500 ml

    • Peripheral IV (PIV) line in right arm infusing D5.45 at 100 ml/hr

    • Postoperative lab draws are completed

    • Vital signs remain stable and dressing dry with a Hemovac drain present.

    • Patient is discharged back to medical-surgical unit after a two-hour PACU stay.

  • Post-operative Medications include:

    • Insulin 6 units Regular, 15 units Lantus (Glargine) subcutaneously every night

    • Aspirin 325 mg orally daily

    • Cilostazol 100 mg orally twice a day

    • Morphine 2 mg IVP every 3 hours for incisional pain

Safe Hand-off from PACU to Med-Surg Unit

  • Using SBAR (Situation, Background, Assessment, Recommendation), the PACU nurse will provide a concise report to the med-surg unit nurse upon transfer of Mr. Egan.

  • The med-surg nurse must perform immediate assessments and interventions for Mr. Egan upon receiving him in his room.

Postoperative Phase: Nursing Process Continuation

  • Important actions during the postoperative phase include:

    • Frequent vital signs checking

    • Dressings management

    • Pain control measures

    • Deep Vein Thrombosis (DVT) prevention with Sequential Compression Devices (SCDs)

    • Techniques for splinting incision

    • Incentive spirometry for engaging in cough and deep breathing

    • Early ambulation and patient teaching

Preventing Post-Surgical Complications: Respiratory

  • Common respiratory complications include:

    • Atelectasis: Incomplete expansion/collapse of alveoli due to retained mucous, leading to poor gas exchange.

    • Pneumonia: Inflammation of alveoli resulting from infection or aspiration of foreign materials.

    • Pulmonary embolism (PE): A traveling blood clot that can obstruct pulmonary vessels.

  • Assessment includes:

    • Airway patency, breath sounds, vital signs including pulse oximeter, and sputum characteristics.

Nursing Management: Respiratory Diagnoses

  • Possible nursing diagnoses include:

    • Ineffective airway clearance

    • Ineffective breathing pattern

    • Impaired gas exchange

    • Risk for aspiration

  • Goals: Patient maintains stable respiratory status. Nursing interventions may include:

    • Frequent assessment and monitoring of breath sounds and oxygenation status

    • Positioning to maximize ventilation

    • Encouragement of coughing & deep breathing exercises, turning, and ambulation

    • Teaching reinforcement with use of incentive spirometer

Preventing Cardiovascular Complications

  • Key cardiovascular complications include:

    • Low potassium (hypokalemia)

    • Poor tissue perfusion/DVT (Deep Vein Thrombosis)

    • Orthostatic hypotension and syncope

    • Hemorrhagic shock due to blood loss

Nursing Management: Cardiovascular Diagnoses

  • Possible diagnoses in cardiovascular management can include:

    • Decreased cardiac output

    • Deficient fluid volume

    • Excessive fluid volume

    • Ineffective peripheral tissue perfusion

    • Activity intolerance

  • Goals: Patient maintains stable cardiovascular status, which includes:

    • Frequent monitoring of vital signs, laboratory results, and comprehensive assessments

    • Early ambulation and leg exercises to prevent thrombus formation

    • Education on safe position changes and movements

Preventing Neurologic Complications

  • Key neurologic complications include:

    • Postoperative cognitive dysfunction

    • Delirium

    • Anxiety and depression

    • Alcohol withdrawal (DT=Delirium Tremens)

Nursing Management: Neurologic/Psychologic Diagnoses

  • Possible nursing diagnoses include:

    • Disturbed Energy Field

    • Risk for Injury

    • Acute Confusion

    • Anxiety/Fear

    • Ineffective Coping

    • Disturbed Body Image

  • Goals: Patient regains stable neurologic status, requiring frequent assessments of neurologic function.

Preventing Pain and Discomfort

  • Pain can result from:

    • Surgical trauma, muscle spasms, anxiety, and fever

  • Nursing Management:

    • Detailed pain assessment with focus on both self-reported and non-verbal indicators

    • Common nursing diagnoses: Acute Pain and Anxiety

    • Goal: Patient maintains an acceptable level of physical comfort

Managing Pain: Nursing Interventions

  • Interventions may include:

    • Education and communication focusing on positive expectations

    • Administering ordered medications such as NSAIDs, opioids, and PCA (Patient-Controlled Analgesia)

    • Non-pharmacological comfort measures (touch, positioning, distraction techniques)

Managing Fever as a Potential Complication

  • Fever may serve as an indicator for:

    • Inflammation, wound infection, respiratory or urinary tract infections, and septicemia

  • Assessments:

    • Monitor vital signs, skin color, and temperature, and note early signs/symptoms of infection

  • Nursing diagnoses might include Hyperthermia and Ineffective Thermoregulation

Gastrointestinal Complications

  • Common gastrointestinal issues include:

    • Nausea, vomiting, abdominal distention, and constipation

    • Paralytic ileus: A complication where there is a loss of intestinal motility.

  • Assessment for Complications:

    • Monitor the abdomen, auscultate for bowel sounds, and assess for nausea

    • Document any characteristics of vomiting

Nursing Management: Gastrointestinal Diagnoses

  • Nursing diagnoses regarding GI issues may include:

    • Nausea

    • Risk for Aspiration

    • Risk for Deficient Fluid Volume

    • Imbalanced Nutrition: Less than Body Requirements

  • Goals: Patient will progress to WDL (within defined limits) regarding GI functioning.

  • Interventions include administration of antiemetic medications and gradual diet advancement based on provider orders.

Urinary Complications

  • Common urinary complications include:

    • Urinary retention possibly due to:

      • Anesthesia effects, surgical position and immobility, or renal failure.

  • Key assessments involve monitoring urine output (minimum output = 30 ml/hour) and examining urine characteristics.

Nursing Management: Urinary Diagnoses

  • Nursing diagnoses include:

    • Impaired Urinary Elimination

    • Urinary Retention

  • Goals: Patient regains WDL urinary function, with assessments for adequate voiding and fluid intake.

  • Treatment plan may involve positioning, providing privacy, and potentially catheterization if needed.

Integumentary Complications

  • Importance:

    • Approximately 70% of post-operative deaths are attributed to surgical site infections.

  • Common integumentary complications include:

    • Wound infection, wound dehiscence, and evisceration

  • Risk Factors include chronic illness, nutritional deficiency, obesity, elderly patients, immunocompromised states, and diabetes.

Nursing Management: Integumentary Diagnoses

  • Possible nursing diagnoses can include:

    • Impaired Tissue Integrity

    • Risk for Infection

  • Goals: Patient experiences progressive wound healing without infection/complications.

  • Interventions may involve regular assessment of the surgical site, ensuring adequate fluid and nutritional intake, and careful documentation of any changes.

Evaluation

  • Post-operative evaluation requires reassessment of patient outcomes to reflect on whether initial pre-operative objectives were achieved following surgery.

Mr. Egan: Post-operative Considerations

  • Key considerations for Mr. Egan’s post-operative phase focusing on preventing complications based on his history of smoking, heart disease, and diabetes.

  • Discharge Teaching:

    • Maintaining comfort, promoting healing, wound care, activity levels, hydration, medication review, and identifying signs/symptoms of possible complications (wound infection, pneumonia, DVT).

Venous Thromboembolism (VTE)

  • Definition: Thrombus refers to a blood clot while thrombophlebitis is the formation of a clot.

  • Pulmonary Embolism (PE): A serious risk associated with thrombophlebitis.

  • Virchow’s Triad: Factors contributing to thrombus formation include:

    1. Hypercoagulability

    2. Endothelial damage

    3. Venous stasis

  • Assessment of VTE: Signs include calf or groin tenderness, unilateral swelling of a leg, localized edema, with discussions around the use of venous duplex ultrasonography or D-dimer tests for diagnosis.

Non-surgical VTE Management

  • Includes bed rest, preventive measures, and drug therapy involving anticoagulants such as:

    • Unfractionated heparin

    • Low-molecular-weight heparin

    • Warfarin, and thrombolytics

Surgical Management of VTE

  • Surgical interventions may involve thrombectomy or inferior vena cava interruption if necessary based on patient case.

Venous Insufficiency

  • Characterized by incompetent valves in the lower extremities, leading to blood pooling.

  • Symptoms involve cramping and aching legs, with assessments focusing on warmth, pulse quality, hair distribution, and possible venous stasis ulcers.

Management of Venous Insufficiency

  • Encouragement of position changes, wearing compression stockings, and maintaining hydration are key components.

  • May require referral for vascular specialists or wound care for more severe presentations.

Arterial Insufficiency

  • Decreased blood flow due to atherosclerotic changes can lead to intermittent claudication, cool extremities, and color changes.

  • Arterial ulcers exhibit characteristics different than venous ulcers, often appearing rounder and with minimal drainage.

Management of Arterial Insufficiency

  • Education and lifestyle changes including diet modification, limiting ambulation, smoking cessation, and potentially pharmacological management with statins for cholesterol control are essential.