AH 1 Exam 1: Care of Perioperative Pts
Latex Allergies/Sensitivities
*6 RISK FACTORS* genetic predisposition children with spina bifida urogenital abnormalities spinal cord injuries hx of multiple surgeries (increased exposure) healthcare professionals *5 CMs* urticaria rhinorrhea bronchospasm - more serious compromised respiratory status circulatory collapse & death trouble breathing 4 CARE identify those at risk latex free environment latex free equipment *FIRST/priority case of care* - *schedule this pt as first in the morning for surgery*
Nursing Considerations for the Older Preoperative Patient
*9 COMORBIDITIES* Greater incidence of chronic illnesses Greater incidence of malnutrition More Allergies Increased risk of cardiopulmonary complications postop Increased risk for falls Mental Status changes Age related changes in renal and liver function Decreased Immune System Delayed wound Healing *9 Age Related Changes As Surgical Risk Factors* DECREASED: Cardiac output Renal perfusion Peripheral Circulation Blood oxygenation Lung vital capacity Reaction time INCREASED: BP Risk for skin damage Deformities r/t osteoporosis or arthritis (causes perfusion interference and pain) Elderly have: more comorbidities slow wound healing decreased function decreased sensory perception/coordination
PACU Assessment - 19 Components
*PRIORITY ASSESSMENT: airway/ventilation* *VS Monitored*: q15m x 4 q30m x 2 q2h x 4 q4h x 1-2 skin color/condition (mark and outline drainage on dressing - reinforce dressing, surgeon changes 1st dressing) cyanosis hypothermia electrolyte imbalances N/V drainage tubes for proper function I&O *q15m - q1hr* as prescribed signs of hypo/hyper-volemia *bladder distention* - 8 hrs to void, if not - bladder scan then in and out cath - need at least 30 mL/hr for discharge urinary catheter for patency color, consistency, amt of urine surgical wound, site, dressings pain movement of extremities LOC ECG Aldrete Scoring *6 PACU DISCHARGE CRITERIA*: Aldrete at least 9-10 stable VS no bleeding return of reflexes minimal wound drainage UOP at least *30 mL/hr*
cath removed by post op day 1
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Emergency Evisceration Care
1. *Call for help! Instruct the person who responds to notify the surgeon or Rapid Response Team* immediately and to bring any needed supplies into the patient's room. 2. *Stay with the patient*. 3. *Cover the wound with a nonadherent dressing premoistened with warmed sterile normal saline*. NOTE: The supplies needed for this emergency should be in the patient's room, especially if the patient is at high risk for dehiscence or evisceration. 4. *If premoistened dressings are not available, moisten sterile gauze or sterile towels in a sterile irrigation tray with sterile saline and then cover the wound*. 5. *If saline is not immediately available, cover the wound with gauze* and then moisten with sterile saline using a sterile irrigation tray as soon as someone brings saline. 6. Do not attempt to reinsert the protruding organ or viscera. 7. While covering the wound, note the patient's response and *assess for CMs of shock*. 8. Place the patient in a *supine position with the hips and knees bent*. 9. Raise the *HOB 15 - 20 degrees*. 10. Take VS, and document them. NOTE: If the person who answered the call for help is back in the room before this, instruct him or her to take vital signs while you focus on covering the wound and repositioning the patient. 11. Provide support and reassurance to the patient. 12. Continue assessing the patient, including *VS assessment, q 5 - 10 minutes until the surgeon arrives*. 13. Keep dressings continuously moist by adding warmed sterile saline to the dressing as often as necessary. *Do not let the dressing become dry*. 14. When the surgeon arrives, report your finding and your interventions. Then follow the surgeon's directions. 15. Document the incident, the activity the patient was engaged in at the time of the incident, your actions, and your assessments. feel something "pop" inspect RF: obese DM pt cough without splinting STAY WITH PT, call for help cover with sterile towel soaked in sterile saline have pt lay supine with knees bent do NOT try to put organs back in monitor for shock (low BP, high HR) NOTIFY provider ASAP
Venous Thrombus Embolism (VTE)
9 RISK FACTORS obesity 40+ hx of cancer or decreased CO decreased mobility/immobility spinal cord injury hx of VTE, PE, varicose veins, edema oral contraceptives smoking hip fracture, total hip/knee surgery <<<<PREVENTION/CARE (6)>>>> antiembolism stockings (TED or Jobst) Pneumatic Compression Devices leg exercises mobility - do this early pharmocological agents (*Lovenox, Heparin*) SCDs start prevention during preop!
Local Anesthesia
ADMIN: topically and /or injection briefly disrupts *sensory nerve* impulse transmission *from specific body area/region* Patient *remains conscious, able to follow instructions*
Aldrete Score Card
ALDRETE SCORE PRE POST Activity Able to move 4 extremities voluntarily or on command = 2 Able to move 2 extremities voluntarily or on command = 1 Able to move 0 extremities voluntarily or on command = 0 ________________________________________________________ Respiration Able to deep breathe and cough freely = 2 Dyspnea or limited breathing = 1 Apneic = 0 ________________________________________________________ Circulation BP" 20% of Preanesthetic level = 2 BP" 20-50% of Preanesthetic level = 1 BP" 50% of Preanesthetic level = 0 ________________________________________________________ Consciousness Fully Awake = 2 Arousable on calling = 1 Not responding = 0 *determines if pt can leave* j<<<<ust know categories>>>>
Complications of Local or Regional
ASSESS: observe for *systemic toxic reaction* (CNS stimulation followed by cardiac depression) 8 CMs: restlessness excitement incoherent speech seizures tremors HA blurred vision increase pulse, BP, RR 5 INTERVENTIONS establish open airway fast acting barbiturate administer oxygen epinephrine for unexplained bradycardia notify surgeon
Arrival in Post Anesthesia Care Unit (PACU or Receiving Unit)
Anesthesia and Circulating Nurse: accompany patient to receiving unit (PACU or ICU) handoff report given to PACU nurse or to receiving unit nurse (*NPSG-verbal handoff*) *PRIORITIES FOR CARE IN IMMEDATE POSTOP PERIOD*: airway patency gas exchange circulatory status (ABCs) General anesthesia/moderate sedation: monitor respiratory status Epidural/spinal anesthesia: monitor motor/sensory function *PRIORITY: oxygen via face mask*
Preop NDs
Anxiety r/t lack of knowledge about surgical routine Potential for altered body image *High risk for injury r/t pre-anesthetic medications* - PRIORITY Fear of pain r/t surgical procedure Deficient knowledge Anxiety Disturbed sleep pattern *Powerlessness* - was emphasized in class
Management of Dehiscence (wound opening)
Apply sterile non-adherent dressing (Telfa) or saline dressing to the wound Wound left open and treated Cleaning and packing of wound Wound vacuum Surgery to removed infected tissue or to close wound
Preoperative Period
Begins when patient is scheduled for surgery (can start in physician's office) ends at time of transfer to surgical suite ROLE educate advocate promote health and safety *prevention measures* COLLECTING HISTORY (13) age tobacco, ETOH, or illicit substance use (*cocaine* - *increased risk of heart attacks* - educate about risks and *cancel surgery if high risk* aka recent cocaine use) current medications alternative practices (Herbal meds - *gingko bilboa* - *increases bleeding risk*) (acupuncture, folk remedies) medical hx (*lung and cardiac disease* - *increased stress on heart*) (hx blood transfusions) prior surgeries (hx of tolerance, experiences, malig. hyper) *prior experience with anesthesia*, pain control, and management of N/V (*malignant hyperthermia*, determine if difficult to intubate, *determine allergic reactions*) autologous or directed blood donations (*locate blood supply and know pt blood type*) allergies (*bananas - latex allergy, shellfish - contrast dye/iodine allergy*) family hx type of surgery planned pt knowledge of perioperative period (*teach to alleviate pt anxiety*) adequacy of patient's support system (care, home, *start planning upon admission in discharge plan* - *refer to social workers*, ensure necessary equipment, *extend hospital stay if support is inadequate*) an extensive history is important for determining complications
Lab Assessment
CBC - infection H&H - blood loss Electrolytes Serum creatinine ABG's - resp pts, chest surgery, mechanical ventillation, cardiac disease Labs based on hx (DM) Type of surgical procedure ( i.e Pancreatectomy (amylase), Thyroidectomy( TSH) and clinical manifestations after surgery <<<*NOTIFY of hypoxemia*>>> Changes in electrolyte, hematocrit, and hemoglobin levels often occur during the first 24 to 48 hours after surgery because of blood and fluid loss and the body's reaction to the surgical process. *Fluid loss with minimal blood loss may cause elevated laboratory values.* Such test results appear increased but actually are concentrated normal values. *An indication of INFECTION*: is an increase in the band cells (immature neutrophils) in the WBC differential count, known as a "left-shift" or *bandemia*. The source of infection may be the respiratory system, urinary tract, surgical wound, or IV site. Obtain specimens for C&S testing, and *monitor the culture reports at 24, 48, and 72 hours*. *Notify the surgeon of positive culture results*. Arterial blood gas (ABG) tests may be needed for patients who have respiratory or cardiac disease, those undergoing mechanical ventilation after surgery, and those who had chest surgery. Review ABG results, and notify the surgeon of any acid-base imbalance or hypoxemia that indicates poor GAS EXCHANGE. Urine and kidney laboratory tests also may be obtained (e.g., urinalysis, urine electrolyte levels, serum creatinine levels). Other laboratory tests depend on the diagnosis, type of surgical procedure, and other health problems. Examples are a serum amylase level for a patient who had pancreatic surgery and a blood glucose level for a patient with diabetes.
Pain Assessment
Causes: Surgical Wound Tissue Manipulation Drains Positioning, ETT (endotracheal tube) Prior experience Assess need for medication according to NPSGs: Consider type of surgery Extent of surgery Length of surgical procedure *Physical & Emotional Signs of Acute Pain*: Increased HR and BP Increased RR Diaphoresis Restlessness Confusion (older adults) Wincing, moaning, crying give pain med early proph *do NOT put pillow under pt or use knee gadges* (??) - DVT, occlude blood
Administering Regularly Scheduled Meds
Consult with physician and anesthesia provider for instructions *Drugs for certain conditions often allowed with a sip of water*: Cardiac disease (*Beta Blockers*-SCIP - *take morning of surgery* - decreases workload of heart, better outcomes for pt postop) Respiratory disease Seizures HTN <<<<INSULIN: may be give in decreased or divided dose!>>>> *Insulin* *call* surgeon or anesth to *ask if OK to give* doses are adjusted or pt is covered in T5 Purpose of Insulin Admin: important for glucose levels for *healing postop*
Categories of Surgical Procedures
DIAGNOSTIC determines origin and cause of disorder ex. Breast bx, ex-lap CURATIVE resolves health problem by repairing or removing cause ex. Cholecystectomy, Appendectomy, Hysterectomy RESTORATIVE improves patient's functional ability ex: Total Knee replacement, implants PALLIATIVE relieves symptoms of disease process, but does NOT cure ex. Debulking COSMETIC alters/enhances personal appearance
Preventing Wound Infection and Delayed Healing
Dressings - 1st change usually done by surgeon <<<*Before the first dressing change, reinforce the dressing (add more dressing material to the existing dressing) if it becomes wet from drainage*.>>> Document the added material, as well as the color, type, amount, and odor of drainage fluid and time of observation. Assess the surgical site at least every shift, and report any unexpected findings to the surgeon Reinforce dressing if becomes wet from drainage Assess surgical site every shift or prn Change dressings as ordered or per policy using aseptic technique Dressing changes are prescribed by the surgeon; Transparent: 3-6 days Wound/Suture Line: changing gauze dressings at least once during a nursing shift or daily and may include cleaning the area with sterile saline or some other solution. Some suture lines are left open to air without any dressing to cover the incision. For large dressing changes or drain removal, offer the patient a prescribed analgesic before the procedure. Always assess the skin for redness, rash, or blisters in areas where tape has been used. Tape can cause a skin reaction after surgery even among patients who are not known to be tape sensitive. *removed 5 to 10 days after surgery, although this varies up to 30 days* depending on the type of surgery and the patient's health. After sutures or staples are removed, the incision may then be secured with Steri-Strips, which stay in place until they fall off on their own. *The surgeon or the nurse removes the sutures or staples, depending on the agency's policy*. Clean the incision with the prescribed solution before removing sutures or staples. Before removing sutures, examine the condition and healing stage of the wound. First remove every other suture or staple and re-assess the wound for integrity. If wound healing is progressing normally, the rest of the sutures or staples may then be removed. *If the wound does not appear to be healing well or if any manifestations of INFECTION are present, notify the surgeon before removing any sutures* Drains - Provide exit route for air, blood, bile; help prevent deep infections, abscess formation during healing Penrose: Change a damp or soiled dressing, and carefully clean under and around the Penrose drain. Then place absorbent pads under and around the exposed drain to prevent skin irritation, wound contamination, and INFECTION. Whether sutured in place or not, the drain can be dislodged or pulled out accidentally during a dressing change. It is also possible for the drain to slip back through the wound into the patient. Usually this complication is prevented when the drain is first placed in the OR. The surgeon pins a sterile safety pin through the drain at an angle perpendicular to the drain and the wound, which prevents the drain from slipping. As the wound heals, the surgeon or nurse shortens (advances) the drain by pulling it out a short distance and trimming off the excess external portion so that only 2 to 3 inches of drain protrudes through the incision. *The safety pin must be repositioned each time the drain is advanced. The drain remains in place until drainage stops* JP: Use *sterile technique to empty the reservoir*. Record the amount and color of drainage during every nursing shift or more often if prescribed. After emptying and compressing the reservoir to restore suction, *secure the drain to the patient's gown (never to the sheet or mattress) to prevent pulling and stress on the surgical wound*. Drug therapy- irrigation to treat wound infection *The need for these antibiotics is re-evaluated at 24 hours after surgery* Surgical management required for complicated or poorly healing wounds. Including Debridement Wounds that become infected and open: *dressing changes and systemic antibiotic therapy*. Depending on the surgeon's prescription, *irrigate the wound (e.g., with sterile saline, hydrogen peroxide, povidone-iodine, or acetic acid*), *loosely pack it with solution-soaked gauze* (e.g., neomycin, gentamicin, iodoform, povidone-iodine, saline, or acetic acid), and *cover the wound with dry, sterile dressings*. These *wet-to-damp dressing changes, done 1 - 3 times daily*, promote healing from within the wound and débridement (removal of the infected or dead tissue) as the wound heals. *Negative pressure wound care systems such as Wound VAC may be prescribed to help close the wound*. Prevention- pressure ulcer formation Emphasize the importance of *early deep-breathing exercises to prevent forceful coughing*. Urge the patient to *bend the hips when in the supine position to reduce tension on a chest or abdominal wound*. Remind him or her to *always splint the chest or abdominal incision when coughing*. Promote wound healing and protection of the skin, especially for the older patient Management of Dehiscence. If dehiscence (wound opening) occurs, apply a *sterile nonadherent (e.g., Telfa) or saline dressing to the wound and notify the surgeon*. Instruct the patient to *bend the knees and to avoid coughing*. A wound that becomes infected dehisces by itself, or it may be opened by the surgeon through an incision and drainage (I&D) procedure. In either case, the wound is left open and is treated as described previously. Management of Evisceration. An evisceration (a wound opening with protrusion of internal organs) is a surgical emergency. *Provide support* by explaining what happened and reassuring the patient that the emergency will be handled competently. When a surgical wound evisceration occurs, *one nurse tends to the patient while another nurse immediately notifies the surgeon*
Pt Preop Prep
EDUCATE PT (11) explore knowledge level explain surgical procedure make sure pt knows what to expect: hear, smell, feel cold, people, noises, lights get baseline vitals CV hx of embolism, PE, strokes, MIs kidney function - esp in elderly for anesthesia response baseline neuro exam - never attribute grogginess to anesthesia nutrition: preablbumin and albumin levels to guage wound healing labs 24-48 hours before surgery admin anticoags - know levels (PT, INR, aPTT) ANXIETY: reinforce teaching from physician - be comforting encourage communication promote rest use distraction teach family about surgical routine and pt needs MEDS: know categories and purposes anticholinerg: prevent aspiration, famotidine, benadryl <<<<NPO 6-8 hr before>>>> stool softener: prevent vagal response - don't let BP drop too low relaxation: benzos, sedatives, hypnotics opioids: pain relief and sedation, morphine, meperidine, methadone DIETARY RESTRICTIONS NPO *OBTAIN INFORMED CONSENT* *surgeon* obtains *signed consent BEFORE sedation and/or surgery* NURSE: *clarifies facts and dispels myths about surgery* NURSE: is *not responsible for providing detailed information about procedure* NURSE: *witness signature and check for completion (pt signed)* *pts may sign with "X"* - must be *witnessed by 2 people* in emergency, *telephone authorization* - *2 people listen/witness* special permits required for some procedures (sterilizations or experimental procedures) - *respect wishes* if pt seems confused or there is some doubt: do NOT sign and NOTIFY surgeon POST OP EXERCISE TCDB, incentive spirometer, lower extremity exercise PAIN MANAGEMENT *tell pt pain will be managed but not completely alleviated* *PCA pump instructions* - tell family members to not touch SPLINTING BOWEL/INTESTINAL PREP enema or laxative prevents injury to colon; reduces number of intestinal bacteria reduces risk of perontinitis pt has increased risk of fall, tired SKIN PREP *shower using antiseptic solution* chlorhexadine *even in nose* *hair removal via clippers or depilatories* I (NPSG) break in skin increases risk for infection shaving of hair creates risk for infection - *do NOT shave* *START IV ACCESS* use *large bore needle* TUBES, DRAINS *make pt aware of possibilities of machines, tubes, catheter* PREOP MEDS Anxiolytics reduce anxiety Sedatives, Hypnotics promote relaxation Anticholinergics reduce nasal and oral secretions prevent laryngospasm reduce vagal-induced bradycardia H2 Histamine Blockers inhibit gastric secretion Opioids *decrease amount of anesthetic needed for induction and maintenance*
Preoperative Chart Review -5
Ensure all documentation, preop procedures, and orders are complete Check surgical consent form and others for completeness - look for pts sig Inform patient that area (site) will be marked before procedure begins *Document allergies, height, and weight* Ensure all laboratory and diagnostic test results are in chart and abnormal results noted
Fluid, Electrolyte, and Acid Base Balance Assessment
Fluid volume deficit or fluid volume overload may occur after surgery. Na, K, Cl, and Ca imbalances also may result RF: older or debilitated patients, DM Crohn's disease HF I&O: IV fluids vomitus urine wound drainage NGT drainage *know the total I&O from both the OR and the PACU* to assess fluid balance accurately and to complete the 24-hour I&O record. *Na, K, Ca, Cl* Hydration status: inspect the color and moisture of mucous membranes; the turgor, texture, and "tenting" of the skin (*test over the sternum or forehead of an older patient*); the amount of drainage on dressings; and the presence of axillary sweat. Measure and compare total output (e.g., NG tube drainage, urine output, wound drainage) with total intake to identify a possible fluid imbalance patients who have heart disease or kidney disease may need a longer period of I&O measurement IV fluids: *Isotonic solutions* such as lactated Ringer's (LR), 0.9% sodium chloride (normal saline), and 5% dextrose with lactated Ringer's (D5/LR) *are used for IV fluid replacement* in the PACU. After the patient returns to the medical-surgical unit, the type and rate of IV infusions are based on need Acid Base Balance - rapid breathing Examine arterial blood gas (ABG) values and other laboratory values
Neuro Assessment
GENERAL ANESTHESIA & SEDATION: Cerebral Functioning LOC (On the medical-surgical nursing unit, assess the level of consciousness every 4 to 8 hours) Awareness (simple commands, open eyes and take deep breath) Observe for lethargy, restlessness, or irritability, and test coherence and orientation. Determine awareness by observing responses to calling the patient's name, touching the patient, and giving simple commands such as "Open your eyes" and "Take a deep breath." Eye opening in response to a command indicates wakefulness or arousability but NOT awareness AAOx3 Expect return to preoperative levels of consciousness *Order of Return to Consciousness After General Anesthesia*: 1. Muscular irritability 2. Restlessness and delirium 3. Recognition of pain 4. Ability to reason and control behavior EPIDURAL/SPINAL ANESTHESIA: The patient who had epidural or spinal anesthesia remains in the PACU until sensory function (feeling) and voluntary motor movement of the legs have returned (see Table 16-2). Test for the return of sympathetic nervous system tone by gradually elevating the patient's head and monitoring for hypotension. *Begin this evaluation after the patient's sensation has returned to at least the spinal dermatome level of T10* Motor and Sensory Functioning *Order of Return of Motor and Sensory Functioning After Local or Regional Anesthesia*: 1. Sense of touch 2. Sense of pain 3. Sense of warmth 4. Sense of cold 5. Ability to move TPWCM
Community Based Care
Home Care Management Self Management Education • Prevention of infection • Care and assessment of the surgical wound • Management of drains or catheters • Nutrition therapy • Pain management • Drug therapy • Progressive increase in activity Prevention of infection - hand washing, shower Wound care Management of drains Pain management Medications - antibiotic instructions, pain meds Activity level - *can't lift to strain*, return to work, drive *A patient whose work involves a moderate amount of physical labor may return to work about 6 weeks after abdominal surgery* Nutrition Therapy - supplements, Ensure, *high in protein, vit C, Zinc* A *diet high in protein, calories, and vitamin C promotes wound healing*. *Supplemental vitamin C, iron, zinc*, and other vitamins are often prescribed after surgery to aid in wound healing and red blood cell formation. Healthcare Resources *Always ensure that the patient and family receive written discharge instructions to follow at home*. Assess the patient's and family's understanding of the instructions by *having them explain the instructions in their own words*.
Moderate/Conscious Sedation
IV delivery of: opiod sedative hypnotic patient maintains own airway responds to verbal commands (easily arousable) *gag reflex present* short acting amnesia *Administered by CRNA, Anesthesiologist, or credentialed RN (*ACLS and/or PALS certification usually required*) under physician supervision* POST INTERVENTIONS continue monitoring VS and LOC *continue monitoring until pre-procedural baseline levels are achieved* 5 COMPLICATIONS airway obstruction respiratory depression cardiac dysrhythmias hypotension anaphylaxis 5 DISCHARGE CRITERIA baseline LOC VS stable for 30-90 minutes cough/deep breathe take PO fluids no N/V, SOB, or dizziness *DRUG OF CHOICE: profolol*
NANDA NDs
Impaired gas exchange Impaired skin integrity Acute pain Ineffective airway clearance Ineffective breathing pattern Risk for infection Altered tissue perfusion Impaired tissue integrity Nausea and vomiting Urinary retention Constipation PRIORITY *Potential for hypoxemia* r/t effects of anesthesia, pain, opiod analgesics, and immobility *Potential for wound infection and delayed healing* r/t wound location, decreased mobility, drains, drainage, and tubes *Acute Pain* r/t surgical incision, positioning, ETT irritation hypoxemia wound infection pain
Postop Older Adult Skin Care
Improve perfusion to the wound to promote wound healing: ▪ Keep the patient *adequately hydrated* to maintain cardiac output. ▪ Keep the *airway patent*, and provide adequate oxygenation. ▪ <<<Keep the patient's *oxygen saturation on pulse oximetry > 93%*.>>> Conserve the patient's energy: ▪ Allow the patient to sleep in a *darkened, quiet room*. ▪ Administer drugs to combat pain and sleeplessness, as prescribed. ▪ *Provide rest periods* throughout the day. ▪ Control the patient's room temperature. ▪ Assist in ADLs. Place the patient on a safety program to prevent falls, if indicated. Use *strict aseptic technique* in caring for breaks in the integument (e.g., IV or other catheters, indwelling urethral catheter, wound). Maintain the patient's psychosocial health: ▪ Prevent unnecessary stressors. ▪ *Allow the patient liberal visitation of supportive others*. ▪ Enable the patient to use individual successful coping mechanisms. ▪ Keep the patient well groomed and bathed. Protect fragile skin: ▪ *Minimize the use of tape* on the skin. ▪ Use *hypoallergenic tape or Montgomery straps*. ▪ Change dressings as soon as they become wet. ▪ *Lift the patient during transfer or repositioning*.
Psychosocial Assessment
Indications of anxiety include restlessness; increased pulse, blood pressure, and respiratory rate; and crying. The patient may be anxious and ask questions about the results or findings of the surgical procedure. *Reassure the patient that the surgeon will speak with him or her after he or she is fully awake.* If the surgeon has already spoken with the patient, *reinforce what was said*. After the patient returns to the medical-surgical unit, continue the psychosocial assessment and also assess family members for psychological discomfort.
Anesthesia
Induced state of partial or total loss of sensation, occurring with or without loss of consciousness 4 Purposes: block nerve impulse transmission suppress reflexes promote muscle relaxation achieve controlled level of unconsciousness (in some cases) ASA Classification TYPES: ANESTHESIA TYPE DEFINITION AND COMMON USE Field block A series of injections around the operative field Most commonly used for chest procedures, hernia repair, dental surgery, and some plastic surgeries Nerve block Injection of the local anesthetic agent into or around one nerve or group of nerves in the involved area Most commonly used for limb surgery or to relieve chronic pain Spinal anesthesia Injection of an anesthetic agent into the cerebrospinal fluid in the subarachnoid space (see Fig. 15-9) Most commonly used for lower abdominal, pelvic, hip, and knee surgery Epidural anesthesia Injection of an agent into the epidural space Most commonly used for anorectal, vaginal, perineal, hip, and lower extremity surgeries
16 Risk Factors for Postop Complications
Infection Anemia Hypovolemia Electrolyte imbalance Age Pregnancy Respiratory/cardiac disease Diabetes Hepatic/renal disease (metabolism of drugs) Endocrine disorders Immune disorders Coagulation problems (bleeding) Malnutrition/obesity Use of meds Family/social hx - SMOKING Allergies determine in PREOP period!
Anesthesia Complications
MYOCARDIAL DEPRESSION: bradycardia hypotension cyanosis edema ANAPHYLAXIS: cardiac failure allergic symptoms abnormal VS MALIGNANT HYPERTHERMIA AUTONOMIC NS BLOCKADE (spinal/epidural): hypotension bradycardia *N/V* CSF LEAK (spinal and epidural): headache halo around dressing
Postop Pain Meds
Management of Postoperative Pain *MORPHINE* sulfate (Epimorph image, Statex image) IM/IV: *2-15 mg incrementally* Monitor respiratory status. Respiratory depression can be severe and require medical intervention. PO: *10-30 mg q4 hr* Monitor blood pressure. Assess for GI motility and urine output. Hypotension, constipation, and urinary retention can occur. *HYDROMORPHONE* hydrochloride (Dilaudid) IV/IM: 1-4 mg q3-4hr PO: 2-4 mg q3-4hr Monitor respirations. Monitor blood pressure. Monitor for food intolerance. Monitor fluid and electrolyte balance. Assess GI motility. Respiratory depression, hypotension, anorexia, nausea, vomiting, and constipation can occur. *CODEINE* sulfate, codeine phosphate (Paveral image) IM/PO: 15-60 mg q4hr Monitor respiratory status. Monitor for food intolerance. Monitor fluid and electrolyte balance. Respiratory depression, nausea, and vomiting can occur. Assess GI motility. Constipation is common; prophylactic interventions may be indicated. BUTORPHANOL tartrate (Stadol) IM: 1-4 mg q3-4hr IV: 0.5-2 mg Monitor neurologic status and changes in level of consciousness. Monitor respiratory status. Butorphanol can cause increased ICP and respiratory depression. *OXYCODONE* hydrochloride *+ ASPIRIN* (Percodan, Endodan image, Oxycodan image) PO: 1-2 tablets (5-10 mg) q3-4hr Assess GI tolerance of medication. Assess for GI bleeding. Monitor GI motility. The aspirin component can irritate the stomach and could cause GI bleeding. *Monitor coagulation studies (PT, aPTT). Bleeding times and other coagulation study results may be increased because of the aspirin component*. Monitor respiratory status. Respiratory depression and constipation can be caused by the oxycodone component. *OXYCODONE* hydrochloride *+ ACETAMINOPHEN* (Tylox, Percocet, Endocet image, Oxycocet image) 1-2 tablets (5-10 mg) orally every 3-4 hr Monitor blood pressure and respiratory status. Assess for GI motility. Respiratory depression, hypotension, and constipation can occur. Ketorolac tromethamine (Toradol) 15-60 mg IM or IV every 6 hr Monitor for GI bleeding. GI bleeding, ulceration, and perforation can occur. Monitor for kidney effects, especially in older adults. Decreased urine output, increased serum creatinine, hematuria, and proteinuria can occur. Ketorolac is cleared more slowly in older adults. Older persons are more sensitive to the kidney effects of NSAIDs. *IBUPROFEN* (Motrin, Amersol image, Novoprofen image) PO: 300-800 mg q4-6hr Monitor upper GI tolerance of medication. Give with food or milk. Food or milk helps decrease irritation of the stomach. Monitor coagulation studies (PT, aPTT). Assess for signs of bleeding or delayed clotting. Bleeding times and other coagulation study results may be increased. Monitoring leads to early detection of complications.
Management of Evisceration
Medical Emergency-notify Surgeon Do not attempt to reinsert the organs Cover wound with pre-moistened saline nonadherent dressing or Moisten sterile gauze with sterile saline. Keep dressings moist Place supine position with hip and knees bent Monitor VS
Pain Management
Monitor/maintain fluid status Administer *isotonic fluids* as prescribed Maintain patent IV line Monitor/manage pain *Opiods may mask symptoms of anesthetic reaction*, administer with caution Be cautious. Do not further depress respiratory system *After receiving any drug for PAIN, the patient remains in the PACU for a defined period (often 45 to 60 minutes*). Assess for hypotension, respiratory depression, and other side effects. *Within 5 to 10 minutes after an IV injection, assess the effectiveness of the drug* (i.e., on a rating scale) in relieving pain *Opioid analgesics are given during the first 24 to 48 hours after surgery to control acute PAIN* Commonly used drugs: Morphine sulfate, meperidine hydrochloride, hydromorphone hydrochloride, codeine sulfate and ketorolac Use Alternative Therapies *Unless the surgeon prescribes pillow support, place no pillows under the knees, and do not raise the knee gatch*, because this position could restrict circulation and increase the risk for venous thromboembolism. • Control or remove noxious stimuli. • Cushion and elevate painful areas; avoid tension or pressure on those areas. • Provide adequate rest to increase pain tolerance. • Encourage the patient's participation in diversional activities. • Instruct the patient in relaxation techniques; use audio recordings or CDs and breathing exercises. • Provide opportunities for meditation. • Help the patient stimulate sensory nerve endings near the painful areas to inhibit ascending pain impulses. • *Use ice to reduce and prevent swelling*, as indicated. • Find a general position of comfort for the patient. • *Help the patient stimulate the area contralateral (opposite) to the painful area*. *give meds cautiously - not all at once* *The usual dosage for hydromorphone is much smaller (about one-fifth to one-tenth) that of morphine*. Because of the short effect of the *opioid antagonist, monitor the patient's blood pressure and respirations every 15 to 30 minutes until the full effect of the opioid analgesic has passed* *ANTIDOTE: naloxone*
Dietary Restrictions
NPO nothing by mouth for *6 to 8 hours before surgery* Purpose of NPO: decreases risk for aspiration Nursing Role: give patients written/oral directions to *stress adherence* *Surgery can be canceled if instructions not followed* can't smoke, chew gum because it precipitates saliva
Site Marking
National Patient Safety Goal (NPSG) Nurse ROLE: *Ensure that correct site is listed on the consent form* Independent licensed Practitioners performs site marking *Patient should be involved* in marking of site - *put initials on site* *done by surgeon and pt* <<<IF NOT DONE: tell surgeon to do with pt while awake before in operating room>>> *Time Out* *immediately prior to INVASIVE procedure* All members of the team participate *Verifies right*: patient site side/position procedure count equipment
Skin Assessment
Normal Wound Healing: *Clean surgical wound heals at skin level in about 2 weeks* Surgeon removes 1st dressing Assess incision (redness, warmth, drainage,) <<<reinforce dressing>>> Impaired Wound Healing (occurs day 5-10): Dehiscence - separation of wound edges Evisceration - protrusion of organs - medical emergency Described as a "popping" sound coughing Dressings and Drains aseptic technique DELAYS WOUND HEALING: poor nutrition steroids obesity diabetes
Minimally Invasive (Laparoscopic/MIS) and Robotic Surgery
Now common practice *Preferred technique* for many surgery types, including: cholecystectomy joint surgery cardiac surgery splenectomy spinal surgery
Focused Assessment On Arrival to M/S
On Arrival at M/S Unit After Discharge from the PACU: airway breathing mental status surgical incision site temp, pulse, BP IV fluids other tubes
Postop Period
PHASE I Occurs immediately after surgery 1hr - days INT: VS q5-15 minutes. Gradually increases LOCATION: ICU, PACU, ASU aldrete score of at lease 10 PHASE II Prepares pt for care in an extended care environment (i.e. M/S unit, Step Down unit, home, or skill care) 15 min-2hrs LOCATION: M/S unit, SDU, or PACU PHASE III Known as extended care environment (home or hospital unit) INT: VS monitoring BID - once daily assess pt to get baseline <<<<*PRIORITY: airway*>>>> oxygen, airway, suction, IS, TCDB low BP + high HR = bleeding --- < 90% O2 sat - concerned ---
Assessment of Preop Pt
PHYSICAL: BASELINE VS *FOCUSED ASSESSMENT* on problem areas identified from history as well as *surgery site area* RESP age, smoking, obesity expansion of lungs *sleep apnea - get pt to bring machines to hook up after surgery* CV anesth is difficult on heart *don't send to surgery if high BP* - *retake BP because it may be high due to anxiety* no clubbing hx of DVT - *surgery increases risk of DVT formation, start tx before surgery* - compression stockings, SCDs cap refill, heart sounds, rate/rhythm RENAL urine, BPH, nocturia *oliguria/urinary retention common postop* NEURO get baseline function to compare postop FALL RISK because of meds *HIGH RISK, safety measures implemented before surgery* MUSCULOSKELETAL *arthritis - can interfere with maintaining position - causes increased pain postop* deformities, contractures NUTRITIONAL STATUS malnutrition, obesity, depleted vitamin C, B, Ca, K *SKIN* *thorough exam even if healthy* - can find tear or bruise, open sores - *document* *skin breakdown intraop* (during surgery) - TO PREVENT: *pad bony prominences* *REPORT abnormal findings to anesthesia and surgeon* look at history and physical in chart to know what's abnormal PSYCHOSOCIAL anxiety - give meds prophylactically coping ability support system *be calm and maintain pt dignity* LABS lab work needed depends on pt Urinalysis *to detect infection in urine* that can go into blood Blood type and Screen - *this is the PRIORITY preop action!* *within 72 hours of surgery* potential for bleeding - have blood ready CBC *shows infection* PT, aPTT, INR (clotting studies) Electrolytes (CMP or BMP) <<<<*potassium* - *low or high NOTIFY*>>>> - *cancel surgery* - heart attack risk hypokalemia - IV potassium to elevate calcium Creatinine, BUN Pregnancy Test females child bearing *anesthesia harms fetus* DIAGNOSTIC CXR ECG chart 14.3 pg 223 Laboratory Profile NORMAL RANGE FOR ADULTS and SIGNIFICANCE OF ABNORMAL FINDINGS POTASSIUM (K+) 3.5-5.0 mEq/L INCREASED IN: Dehydration Kidney impairment *Acidosis* *Cellular/tissue damage* *Hemolysis of the specimen* DECREASED IN: *NPO with inadequate potassium replacement* *Excessive use of non-potassium-sparing diuretics* V/D Malnutrition *Alkalosis* SODIUM (Na+) 90 yr or younger: 136-145 mEq/L Older than 90 yr: 132-146 mEq/L INCREASED IN: *Cardiac failure* kidney impairment *HTN* Excessive IV fluids with sodium chloride *Edema* Dehydration (hemoconcentration) DECREASED IN: *NG drainage* V/D *Excessive laxatives or diuretics* *Excessive IV fluids with water* *Syndrome of inappropriate antidiuretic hormone (SIADH)* CHLORIDE (Cl−) 90 yr or younger: 98-106 mEq/L Older than 90 yr: 98-111 mEq/L INCREASED IN: *Respiratory alkalosis* Dehydration Kidney impairment Excessive IV fluids with sodium chloride (NaCl) DECREASED IN: *Excessive NG drainage* V/D Excessive diuretics CARBON DIOXIDE (CO2) 60 yr or younger: 23-30 mEq/L 60-90 yr: 23-31 mEq/L Older than 90 yr: 20-29 mEq/L INCREASED IN: *Chronic pulmonary disease* *Intestinal obstruction* *V* *NG suctioning* *Metabolic alkalosis* DECREASED IN: Hyperventilation *Diabetic ketoacidosis* D *Lactic acidosis* *Renal failure* *Salicylate toxicity* GLUCOSE (fasting) 60 yr or younger: 70-110 mg/dL, or 4.1-5.9 mmol/L 60-90 yr: 82-115 mg/dL, or 4.6-6.4 mmol/L Older than 90 yr: 75-121 mg/dL, or 4.2-6.7 mmol/L INCREASED IN: Hyperglycemia Excessive IV fluids with glucose *Stress* *Steroid use* *Pancreatic or hepatic disease* DECREASED IN: Hypoglycemia Excess insulin CREATININE Females: 60 yr or younger: 0.5-1.1 mg/dL, or 44-97 µmol/L 60-90 yr: 0.6-1.2 mg/dL, or 53-106 µmol/L Older than 90 yr: 0.6-1.3 mg/dL, or 53-115 µmol/L Males: 60 yr or younger: 0.6-1.2 mg/dL, or 53-106 µmol/L 60-90 yr: 0.8-1.3 mg/dL, or 71-115 µmol/L Older than 90 yr: 1.0-1.7 mg/dL, or 88-150 µmol/L INCREASED IN: Kidney damage with destruction of large number of nephrons Renal insufficiency Acute kidney injury Chronic kidney disease *End-stage kidney disease (ESKD)* DECREASED IN: *Atrophy of muscle tissue* BLOOD UREA NITROGEN (BUN) Younger than 60 yr: 10-20 mg/dL, or 3.61-7.1 mmol/L 60-90 yr: 8-23 mg/dL, or 2.9-8.2 mmol/L Older than 90 yr: 10-31 mg/dL, or 3.6-11.1 mmol/L INCREASED IN: Dehydration Kidney impairment *Excessive protein in diet* *Liver failure* DECREASED IN: *Overhydration* *Malnutrition* PROTHROMBIN TIME (pro time, PT) 11-12.5 sec, 85%-100%, or 1 : 1.1 patient-control ratio INCREASED IN: Coagulation defect (*bleeding disorder*) *Vitamin K deficiency* DECREASED IN: Coagulation *clotting disorder*, such as *thrombophlebitis or pulmonary embolus* INTERNATIONAL NORMALIZED RATIO (INR) 0.7-1.8 INCREASED IN: *Anticoagulant therapy* (aspirin, warfarin) DECREASED IN: *Extensive cancer* PARTIAL THROMBOPLASTIN TIME, ACTIVATED (aPTT) 30-40 sec INCREASED IN: Coagulation defect (*bleeding disorder*) Anticoagulant therapy (heparin) Liver disease DECREASED IN: Coagulation *clotting disorder*, such as thrombophlebitis or pulmonary embolus *Extensive cancer* WHITE BLOOD CELL (WBC) COUNT (leukocyte count) Total: 5,000-10,000/mm3 INCREASED IN: Infection Inflammation Stress *Tissue necrosis* DECREASED IN: Immune disorder Immunosuppressant therapy HEMOGLOBIN, total Females: 18-44 yr: 12-16 g/dL, or 117-155 g/L 45-64 yr: 11.7-16.0 g/dL, or 117-160 g/L 65-74 yr: 11.7-16.1 g/dL, or 117-161 g/L Males: 18-44 yr: 14-18 g/dL, or 132-173 g/L 45-64 yr: 13.1-17.2 g/dL, or 131-172 g/L 65-74 yr: 12.6-17.4 g/dL, or 126-174 g/L INCREASED IN: Dehydration *Polycythemia* *Chronic pulmonary disease* CHF* DECREASED IN: Blood loss Anemia *Renal failure* HEMATOCRIT Females: 18-44 yr: 35%-45% 45-74 yr: 37%-47% Males: 18-44 yr: 42%-52% 45-64 yr: 39%-50% 65-74 yr: 37%-51% INCREASED IN: Dehydration *Polycythemia* *High altitude* DECREASED IN: Blood loss Anemia *Kidney failure*
INTRAOPERATIVE
PTS
POSTOPERATIVE
PTS
PREOPERATIVE
PTS
Intraoperative Care
Patient Identification Validates consent form Validates correct site Patient's Allergies and previous reactions to Anesthesia or transfusions Presence of Autologous Blood donation Removal of prosthetics, jewelry, piercings, wigs Medical Record Review Advanced Directives and Do Not Resuscitate(DNR) orders Laboratory and Diagnostic Test Results Medical Hx and Physical Examination Findings
Hypoxemia Prevention INT
Patients at risk for hypoxemia (older adults, hx of lung dz) • Partial pressure of arterial oxygen (PaO2) within normal range • Partial pressure of arterial carbon dioxide (PaCO2) within normal range • Oxygen saturation values within normal range Monitor the patient's oxygen saturation (SpO2) for adequacy of GAS EXCHANGE with pulse oximetry at least every hour or more often, according to the patient's condition. Patients who normally have a low PaO2, such as those with lung disease or older adults, are at higher risk for hypoxemia. An older adult is often prescribed low-dose oxygen therapy for the first 12 to 24 hours after surgery to reduce confusion from anesthesia and sedation (Sullivan, 2011). A patient who received moderate sedation with a benzodiazepine such as midazolam (Versed) or lorazepam (Ativan, Nu-Loraz image) may be overly sedated or have respiratory depression sufficient to need reversal with flumazenil (Romazicon) (Chart 16-4). Hypothermia after surgery causes shivering, which increases oxygen demand and can induce hypoxemia. Many rewarming methods can be used, although prevention is more important. The highest incidence of hypoxemia after surgery occurs on the 2nd postoperative day KNOW CMs: Changes in the color of your skin, ranging from blue to cherry red Confusion Cough Fast heart rate Rapid breathing Shortness of breath Sweating Wheezing Interventions Maintain airway: you may need to insert an oral airway if the patient does not already have one. The oral airway pulls the tongue forward and holds it down to prevent obstruction. *If the patient had oral surgery or has clenched teeth, a large tongue, or upper airway obstruction*: insert a nasal airway (nasal trumpet) to keep the airway open. Keep the manual resuscitation bag and emergency equipment for intubation or tracheostomy nearby. For *patients whose only airway is a tracheostomy or laryngectomy stoma*: alert other staff members by posting signs in the room and notes on the chart Monitor SpO2: with *pulse oximetry at q1 hour or more often*, according to the patient's condition. Patients who normally have a low PaO2: such as those with lung disease or older adults, are at higher risk for hypoxemia. An *older adult is often prescribed low-dose oxygen therapy for the first 12 to 24 hours after surgery to reduce confusion from anesthesia and sedation* A *patient who received moderate sedation with a benzodiazepine* such as midazolam (Versed) or lorazepam (Ativan, Nu-Loraz): may be *overly sedated or have respiratory depression sufficient to need reversal with flumazenil (Romazicon)* Hypothermia after surgery causes shivering, which increases oxygen demand and can induce hypoxemia. Many rewarming methods can be used, although prevention is more important. *The highest incidence of hypoxemia after surgery occurs on the 2nd postoperative day*. Position Semi fowler's unless contraindicated (PACU): If the patient cannot have the head of the bed raised, either place him or her in a side-lying position or turn the head to the side to prevent aspiration. Oxygen Therapy: *Hypoxemia is prevented and managed with oxygen therapy*. Apply oxygen by face tent, *nasal cannula*, or mask: eliminate inhaled anesthetic agents, increase oxygen levels, raise the level of consciousness, reduce confusion. *After the patient is fully reactive and stable*: raise the head of the bed to promote respiratory function. For some patients, oxygen therapy may continue through the second day after surgery. *When hypoxemia occurs despite preventive care*: interventions such as respiratory treatments and mechanical ventilation may be used to manage the cause of the hypoxemia Breathing Exercises: Usual *extubation criteria*: ability to raise and hold the head up evidence of thoracic breathing. Help the patient splint the incision, cough, and deep breathe to promote GAS EXCHANGE and eliminate anesthetic agents. *As soon as the patient is awake enough to follow commands*: urge him or her to cough, use the incentive spirometer, and take deep breaths *hourly while awake throughout the postoperative period*. *The patient who is unable to remove mucus or sputum*: requires oral or nasal suctioning. Perform mouth care after removing secretions Movement: Assist the patient out of bed and to ambulate ASAP to help remove secretions and promote ventilation. *Even when the patient has had extensive surgery, the expectation may be to get out of bed the day of or the 1st day after surgery*. If this is not possible: assist him or her to turn at least *every 2 hours (side to side)* and ensure that breathing exercises and leg exercises are performed Early ambulation reduces the risk for pulmonary complications, especially after abdominal, pelvic, or spinal surgery. It increases circulation to extremities and reduces the risk for CLOTTING and venous thromboembolism (VTE), especially deep vein thrombosis (DVT). *The patient may resist getting up, but you must stress the importance of activity to prevent complications*. When indicated, *offer pain medication 30 to 45 minutes before he or she gets out of bed*
Health and Hygiene
People are a source of contamination in the surgical setting (bacteria on skin, hair, and airways) 12 MEASURES TO AVOID TRANSMISSION OF ORGANISMS: surgical attire scrubbing no communicable diseases no open wounds good personal hygiene frequent handwashing minimal jewelry tucked in shirt shoe covers head covers humidity control limit traffic drop sterile field and back away from it - said in class negative pressure (for TB) positive pressure
9 Postop Interventions
Perform *immediate assessment* upon receiving client from OR Maintain airway and ventilation *Keep airway in place if comatose* *Administer O2* Suction secretions if needed Assist with coughing, deep breathing, and splinting Encourage use of incentive spirometer *Reposition at least Q2h* or as prescribed <<<<*Ambulate early* as prescribed>>>> - asap (immobility can lead to DVT, pneumonia, constipation)
Postop and Preop Complications
Postoperative complications usually *related to preop meds*: SEDATIVES respiratory depression, drowsiness, dizziness - risk for injury/falls IVF (0.9% NaCL, LR, D5RL) - isotonic <<<cardiac problems, hypernatremia>>> GI MEDS alkalosis, cardiac problems (H2 blockers), drowsiness Preoperative: Severe anxiety/panic - may administer sedatives Assess for allergic reactions: shellfish - povidone-iodine avocados/bananas/strawberries/other fruit - latex egg/peanut/soy - propofol (Diprivan) (anesthetic agent)
GI System
Postoperative nausea/vomiting (PONV) common after general anesthesia RISK: hx of motion sickness obese pt abdominal surgery - decreased peristalsis opioids *To reduce nausea/vomiting*: ondansetron (Zofran) meclizine (Antivert) dimenhydrinate (Dramamine) scopolomine patch PONV can stress and irritate abdominal and GI wounds, increase intracranial pressure in patients who had head and neck surgery, elevate intraocular pressure in patients who had eye surgery, and increase the risk for aspiration. Assess the patient continuously for PONV. Often patients have nausea as the head of the bed is raised early after surgery. Help reduce this distressing symptom by having the patient in a *side-lying position before raising the head slowly*. Intestinal Peristalsis may be delayed up to 24 hours: Monitor for bowel sounds *Assess for paralytic ileus - abdominal distention, no pain, projectile vomiting, no BM or flatus* The presence of active bowel sounds usually indicates return of peristalsis; however, the absence of bowel sounds does not confirm a lack of peristalsis. *The best indicator of intestinal activity is the passage of flatus or stool* NGT: look at orders, call doc if no orders *Record the color, consistency, and amount of the NG drainage q8hr* (Table 16-3). In some instances, an occult blood test (Gastroccult) may be performed. Normal NG drainage fluid is *greenish yellow.* Red or pink drainage fluid indicates active bleeding, and brown liquid or drainage with a "coffee-ground" appearance indicates old bleeding. Assess that the NG tube is securely taped to the nose, and note any skin irritation <<<<Calculating Nasogastric Tube Drainage Formula:>>>> drainage in collection device - amount of irrigant = true/actual amount of drainage Example A patient's drainage container was marked at 150 mL at 7 AM. At 3 PM, there was 525 mL in the container. During the nursing shift, the nurse instilled 30 mL of saline as an irrigant into the tube four times, as prescribed by the physician. 525-150 = 375 of drainage 30 x 4 = 120 of irrigant 375-120 = 255 actual drainage To prevent aspiration, check the tube placement every 4 to 8 hours and before instilling any liquid, including drugs, into the tube. After gastric surgery, do not move or irrigate the NG tube unless prescribed by the surgeon. Constipation Assess the abdomen by inspection, auscultation, palpation, and percussion and record the elimination pattern to determine whether intervention is needed. Auscultate before palpation or percussion because these two maneuvers can affect peristalsis. Increased dietary fiber intake, the use of mild laxatives or bulk-forming agents, or the use of enemas may be needed. RETURN OF PERISTALSIS gas BM *listen 5 minutes in each quadrant = 20 mins*
Perioperative Phases
Preoperative Intraoperative Postoperative
Preop Nurse Actions and Pt Prep
Remove patient clothing; provide gown Tape rings in place if cannot be removed Ensure patient is wearing ID band <<<< VERIFY: pt case number and have pt state name>>>> REMOVE: 8 dentures prosthetic devices hearing aids contact lenses fingernail polish artificial nails all jewelry metal **this has been a select all Establish IV access (use 18 gauge cath) Administer Preop Meds give *prophylactic antibiotics 1hr prior to incision* - can send antibiotics with pt to surgery if times are changed or tentative Have patient void (because urinary retention/oliguria is common postop) Complete electronic preop checklist (chart review, remove garments, lab work present, etc)
Recognizing Serious Complications of Spinal and Epidural Anesthesia
Respiratory Depression (*can occur if the anesthetic agent moves higher in the epidural or subarachnoid space*) • What is the quality and pattern of the breathing? • What is the respiratory rate and depth? • Is the patient receiving oxygen? At what setting? What is the pulse oximetry result? • *Notify the anesthesia provider if pulse oximetry drops or if the patient is unable to increase the depth of respiration*. Hypotension (can occur when regional anesthesia causes widespread vasodilation) • What is the patient's blood pressure? • Is the blood pressure now lower than in the preoperative or operative period? • Has the pulse pressure widened? • *Notify the anesthesia provider if systolic BP remains > 10 mm Hg below the patient's baseline or if other CMs of shock are present*. • *Notify the anesthesia provider if hypotension is accompanied by other CMs of ANS blockade (bradycardia, nausea, vomiting)*. Epidural Hematoma • Assess for delayed or regressing return of sensory and motor function. • *If return is delayed or is taking longer than usual, alert the anesthesia provider*. • Determine whether sensory or motor deficits are improving, remaining the same, or worsening. • *If motor deficits are worsening or decreasing after brief improvement, notify the anesthesia provider immediately.* • Assess for return of deep tendon reflexes of extremities on both sides. • Compare reflexes from one side of the body with the other. • *If reflexes regress, notify the anesthesia provider* immediately. • Assess pain level in the back. • If the *patient feels pressure or increasing back pain while coughing or straining, notify the anesthesia provider* immediately. Infection (Meningitis) • Assess for mental status changes. • Assess for increasing temperature. • Assess for ability to turn the neck. • *Notify the anesthesia provider immediately for temperature elevations above 101° F (38.3° C), inability to move the neck, acute confusion*. Postdural Puncture Headache • Assess for report of headache in the *occipital region, especially when the patient is permitted to sit upright*.
General Potential Complications of Surgery
Respiratory System Complications • Atelectasis • Pneumonia • Pulmonary embolism (PE) • Laryngeal edema • Ventilator dependence • Pulmonary edema Cardiovascular Complications • Hypertension • Hypotension • Hypovolemic shock • Dysrhythmias • Venous thromboembolism (VTE), especially deep vein thrombosis (DVT) • Heart failure • Sepsis • Disseminated intravascular coagulation (DIC) • Anemia • Anaphylaxis Skin Complications • Pressure ulcers • Wound infection • Wound dehiscence • Wound evisceration • Skin rashes or contact allergies Gastrointestinal Complications • Paralytic ileus • Gastrointestinal ulcers and bleeding Neuromuscular Complications • Hypothermia • Hyperthermia • Nerve damage and paralysis • Joint contractures Kidney/Urinary Complications • Urinary tract infection • Acute urinary retention • Electrolyte imbalances • Acute kidney injury (AKI) • Stone formation
Intraoperative NDs
Risk for Perioperative Positioning Injury r/t improper positioning INT: Proper body positioning Proper padding of OR bed and bony prominences Assess skin for bruising or injury Prevent pressure ulcer formation Prevent obstruction of circulation, respiration, nerve conduction *Adequate number of personnel to assist with patient transfer and positioning* Risk for Infection r/t invasive procedures INT: Adherence to *aseptic technique* Assess the risk for infections by identifying patients with health problems (DM, renal dz, immunocompromised) Implement use of protective drapes, skin closures, and dressings *Administer antibiotics* *Insert drains* - to remove secretions and fluids from the surgical area *Impaired Gas Exchange (hypoventilation) r/t anesthesia, pain, and decreased respiratory effort* INT: *Continuous monitoring (q5minutes)*: breathing circulation cardiac rhythm BP HR Constant presence of Anesthesia provider
7 Members of Surgical Team
Surgeon Surgical assistant Anesthesia providers Preop-holding nurse Circulating nurse Scrub nurse or ORTs (surgical Tech) Specialty nurses (Laser nurse or specialty trained nurses)
Joint Commission
The Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery™ Guidance for health care professionals http://www.jointcommission.org/assets/1/18/UP_Poster.pdf
Surgical Suite Areas
UNRESTRICTED regular clothes/scrubs ex: holding areas, staff break room SEMI-RESTRICTED surgical dress required ex: hallways outside, surgery prep of pt attire RESTRICTED full surgical attire ex: operating room *watch for signs* - emphasized in class
Determinants of Surgery
URGENCY Elective (planned) Urgent (within 24-48 hours) Emergent (immediately) ex: gunshot, stab wounds DEGREE OF RISK Minor ex: hemmroidectomy Major ex: heart EXTENT Simple (localized) Radical (generalized, more severe) Minimally invasive (MIS) (same day send home, small incision, robotic)
Kidney/Urinary System
Urine retention is common early after surgery and requires intervention, such as intermittent (straight) catheterization, to empty the bladder Check for urine retention: Inspect Palpate Percuss Bladder Scan Indwelling foley catheter: Assess urine color Clarity Amount *Report urine output of <30 mL/hr* Urine output should be close to the total intake for a 24-hour period Decrease UOP: hypovolemia renal complications
CV Assessment
VS /Heart Sounds: assessed on admission to the PACU and then at least *q15min until the patient's condition is stable* q15min x4 q30 min x2 q1h x 4 q4h x 4 *Report BP changes* that are 25% higher or lower than values obtained before surgery (or a *15- to 20-point difference, systolic or diastolic*) to the anesthesia provider or the surgeon Decreased BP and pulse pressure and abnormal heart sounds: cardiac depression fluid volume deficit shock hemorrhage effects of drugs BRADYCARDIA: anesthesia effect hypothermia *Older patients are at risk for hypothermia* because of: age-related changes in the hypothalamus (the temperature regulation center) low levels of body fat coolness of the OR suite An increased pulse rate: hemorrhage shock pain Cardiac Monitoring: A *pulse deficit* (a difference between the apical and peripheral pulses) could indicate a *dysrhythmia* *In assessing the VS of a patient who is NOT being monitored continuously* - compare the rate, rhythm, and quality of the apical pulse with the rate, rhythm, and quality of a peripheral pulse, such as the radial pulse Peripheral Vascular Assessment: Compare distal pulses on both feet for pulse quality, observe the color and temperature of extremities, evaluate sensation and motion, and determine the speed of capillary refill. *Palpable pedal pulses indicate adequate circulation and perfusion of the legs* Monitor for VTE: *any preventive strategies started before surgery are usually needed for at least the first 24 hours after surgery*. Reassess the patient's risk for CLOTTING and VTE and the effectiveness of the preventive strategies *daily*. *Assess the feet and legs* for redness, pain, warmth, and swelling, which may occur with DVT. *Foot and leg assessment* may be performed *once during a nursing shift or once daily* depending on the patient's risk for complications and the facility's or agency's policy
Post Op Complications
add tutor slide airway obstruction hypovolemic shock paralytic ileus
Regional Anesthesia
blocks *multiple peripheral nerves* reduces sensory perception Types: field nerve spinal epidura
major problems in surgery
fluid overload skin breakdown
CSF leak
halo ring around dressing
Respiratory System Assessment - 10 components
immediately on arrival (PACU) *PRIORITY ASSESSMENT*: patent airway and adequate gas exchange Patent airway Adequate gas exchange (talking is NOT good indicator of adequate gas exchange) Presence of artificial airway Oxygen delivery method and concentration Oxygen saturation (>95% or baseline) RR, depth, pattern Lung fields/sounds (no less than 10 bpm and listen over ALL lung fields) Use of accessory muscles, sternal retraction (hypoxia ) Snoring, stridor (airway obstruction) Muscle weakness Check the lungs at least *every 4 hours during the first 24 hours after surgery and then every 8 hours, or more often*, as indicated. Older patients, smokers, and patients with a history of lung disease are at greater risk for respiratory complications after surgery and need more frequent assessment . Obese patients are also at high risk for respiratory complications
Malignant Hyperthermia
inherited muscle disorder (autosomal dominant) *poor thermoregulation* RF: genetics young adults males ONSET: immediately after anesthesia induction several hrs into procedure after termination of anesthetic (succinylcholine , halothanes, isoflurane) PATHO: The reaction begins in skeletal muscle exposed to the drugs, causing increased calcium levels in muscle cells and increased muscle metabolism. Serum Ca and K levels are increased, as is the metabolic rate, leading to acidosis, cardiac dysrhythmias, and a high body temperature. *results in high body temperature and rigid skeletal muscles* EARLY SIGN: an unexpected rise in the end-tidal CO2 level with decrease in oxygen saturation and tachycardia LATE SIGN: Extremely high temp (up to 111.2 F/ 44 C) 9 CMs tachycardia dysrhythmia muscle rigidity (jaw and upper chest) hypotension skin mottling cyanosis myoglobinuria rise in end tidal carbon dioxide elevated temperature 8 INTERVENTIONS: *stop administration of causative agent* intubate if not already provide *100% oxygen* *administer IV dantrolene* as prescribed cool body temp (cooling blanket, iced saline) monitor T, HR, UOP, myoglobinuria *prepare to administer diuretics* as ordered *terminate surgery ASAP* hx - tx with IV dantrolene *ANTIDOTE: IV dantrolene*
Discharge Teaching
meds activity restrictions handwashing add rest from tutor slides
13 Components of the Circulating Nurse Role
protects patient privacy and ensures patient safety reports findings to surgeon and anesthesiologist documentation monitors traffic in the room keep track of fluids communicates with family members - *when surgery starts and q1hr* anticipates needs of the surgical team assesses the amount of urine and the estimated blood loss (EBL) CN and scrub person perform count of equipment, sponges, and towels, sharps - gather and count all equipment reports to receiving unit manage thermoregulation (warm blanket) secures safety straps (there are no side rails) open account and close account 4 hours in surgery can make a stage I pressure ulcer *surgeon will choose desired position* (dorsal recumbent, prone, lithotomy, lateral) CN RESPONSIBILITIES: POSITIONING pad bony prominences maintain body alignment do not position to alter blood flow/breathing avoid pressure FIRE SAFETY oxygen cauterization units sterile saline and gauze pads
General Anesthesia
reversible loss of consciousness induced by inhibiting *neuronal impulses* in several areas of CNS single or combination of agents 4 RESULTS: analgesia amnesia unconsciousness loss of muscle tone and reflexes ADMIN: inhalation IV injection balanced anesthesia (combination of types of agents) 4 COMPLICATIONS: malignant hyperthermia overdose of anesthetic unrecognized hypoventilation intubation complications *STAGES OF GENERAL ANESTHESIA*: Stage 1 (Analgesia and Sedation, Relaxation) *Begins with induction and ends with loss of consciousness*. Patient feels drowsy and dizzy, has a reduced sensation to pain, and is amnesic. *Hearing is exaggerated* - emphasized in class 3 INTERVENTIONS: Close operating room doors, dim the lights, and control traffic in the operating room. (Avoiding external stimuli in the environment *promotes relaxation*.) Position patient securely with safety belts. (Using safety measures in stage 1 prepares for stage 2.) Keep discussions about the patient to a minimum. (Being sensitive to the patient maintains his or her dignity.) Stage 2 (Excitement, Delirium) *Begins with loss of consciousness and ends with relaxation, regular breathing, and loss of the eyelid reflex*. Patient may have *irregular breathing, increased muscle tone, and involuntary movement of the extremities*. *Laryngospasm or vomiting* may occur. Patient is *susceptible to external stimuli*. 4 INTERVENTIONS: Avoid auditory and physical stimuli. (Sensory stimuli can contribute to the patient's response.) Protect the extremities. (Safety measures help prevent injury.) Assist the anesthesiologist or CRNA with suctioning as needed. (Adequate suctioning of vomitus can prevent aspiration.) Stay with patient. (Staying with the patient is emotionally supportive.) Stage 3 (Operative Anesthesia, Surgical Anesthesia) *Begins with generalized muscle relaxation and ends with loss of reflexes and depression of vital functions*. The *jaw is relaxed, and breathing is quiet and regular*. The *patient cannot hear*. *Sensations (i.e., to pain) are lost*. 3 INTERVENTIONS: Assist the anesthesiologist or CRNA with intubation. (Providing assistance helps promote smooth intubation and prevent injury.) Place patient into operative position. Prep (scrub) the patient's skin over the operative site as directed. (Performing procedures as soon as possible promotes time management to minimize total anesthesia time for the patient.) Stage 4 (Danger) *Begins with depression of vital functions and ends with respiratory failure, cardiac arrest, and possible death*. *Respiratory muscles are paralyzed; apnea occurs*. Pupils are *fixed and dilated*. 2 INTERVENTIONS: Prepare for and assist in treatment of cardiac and/or pulmonary arrest. Document occurrence in the patient's chart. (Teamwork and preparedness help decrease injuries and complications and promote the possibility of a desired outcome for the patient.)
PACU Nurse
skilled in the care of patients with multiple medical and surgical problems In-depth knowledge of: A&P anesthetic agents pharmacology pain management extubation *able to make quick decisions* works closely with anesthesiologist and surgeon
Complications Peri
table 18-1 Respiratory GI Neurological Renal Skin- Positioning: Assess skin integrity prior to/following surgery Prevent pressure Document accurate skin assessments *Cardiac arrest* Massive blood loss Anaphylactic reactions May be masked by anesthesia *Airway Obstruction* Choking, noisy respirations, decreased SpO2, cyanosis Keep emergency equipment at bedside *Hypoxia* Administer O2 as prescribed Encourage TCDB Position to facilitate respiratory status *Hypovolemic Shock* Decreased BP and UOP, increased HR, slow cap refill Administer fluids/vasopressors as prescribed RHEUMATOID ARTHRITIS Typical onset (age) 35-45 yr Gender affected Female (3 : 1) Risk factors or cause Autoimmune (genetic basis) Emotional stress (triggers exacerbation) Environmental factors Disease process: Inflammatory Disease pattern: Bilateral, symmetric, multiple joints Usually affects upper extremities first Distal interphalangeal joints of hands spared Systemic Laboratory findings Elevated rheumatoid factor, antinuclear antibody, ESR Common drug therapy: NSAIDs (short-term use) Methotrexate Leflunomide (Arava) Corticosteroids Biological response modifiers Other immunosuppressive agents OSTEOARTHRITIS Older than 60 yr Female (2 : 1) RF: Aging Genetic factor (possible) Obesity Trauma Occupation Degenerative Pattern: May be unilateral, single joint Affects weight-bearing joints and hands, spine Metacarpophalangeal joints spared Nonsystemic Labs: Normal or slightly elevated ESR Common Drug Therapy: NSAIDs (short-term use) Acetaminophen Other analgesics
local -
topical regional nerve block lidocaine don't lose consciousness
Pts should be NPO
until recovered
Emergency Care for Opioid Overdose
• Prepare to administer *naloxone hydrochloride (Narcan) in a dose of 1 to 2 mg IV*. • *Repeat naloxone every 2 - 3 minutes up to 10 mg, as needed*, depending on the patient's response. • Maintain an *open airway*. • Give *oxygen if hypoxia is present or if respirations < 10 breaths per minute*. • Have *suction equipment available* because naloxone can trigger vomiting and a drowsy patient is at risk for aspiration. • Continuously monitor vital signs and level of consciousness for reversal of overdose. • Do not leave the patient until he or she is fully responsive. • Assess the patient for pain because reversal of the opioid overdose also reverses the analgesic effects. • Continue to *monitor patient's vital signs and level of consciousness every 10 - 15 minutes for 1st hour*. Naloxone is eliminated from the body more quickly than is the opioid, and it may induce side effects, including blood pressure changes, tachycardia, and dysrhythmias. • *Determine the need for additional antagonist therapy 1 hour after the patient initially becomes fully responsive*.
In-Depth Emergency Care of Malignant Hyperthermia
• Stop all inhalation anesthetic agents and succinylcholine. • *If an endotracheal tube (ET) is not already in place, intubate immediately*. • *Ventilate the patient with 100% oxygen, using the highest possible flow rate*. • *Administer dantrolene sodium (Dantrium) IV at a dose of 2 - 3 mg/kg*. • If possible, *terminate surgery*. If termination is not possible, continue surgery using anesthetic agents that do not trigger malignant hyperthermia (MH). • Assess arterial blood gases (ABGs) and serum chemistries for *metabolic acidosis and hyperkalemia*. • If *metabolic acidosis is evident by ABG analysis, administer sodium bicarbonate IV*. • If *hyperkalemia is present, administer 10 units of regular insulin in 50 mL of 50% dextrose IV*. • Use active cooling techniques: ▪ Administer iced saline (0.9% NaCl) IV at a rate of 15 mL/kg every 15 minutes as needed. ▪ Apply a *cooling blanket over the torso*. ▪ Pack bags of ice around the patient's axillae, groin, neck, and head. ▪ Lavage the stomach, bladder, rectum, and open body cavities with sterile iced normal saline. • Insert a nasogastric tube and a rectal tube. • Monitor core body temperature to assess effectiveness of interventions and to *avoid hypothermia*. • Monitor cardiac rhythm by electrocardiography *(ECG)* to assess for dysrhythmias. • Insert a *Foley catheter to monitor urine output*. • Treat any dysrhythmias that do not resolve on correction of hyperthermia and hyperkalemia with antidysrhythmic agents other than calcium channel blockers. • Administer IV fluids at a rate and volume sufficient to *maintain urine output above 2 mL/kg/hr*. • Monitor urine for presence of blood or myoglobin. • *If urine output falls < 2 mL/kg/hr, consider using osmotic or loop diuretics*, depending on the patient's cardiac and kidney status. • Contact the Malignant Hyperthermia Association of the United States (MHAUS) hotline for more information regarding treatment: (800) 644-9737. • Transfer the patient to the intensive care unit (ICU) when stable. • Continue to monitor the patient's temperature, ECG, ABGs, electrolytes, creatine kinase, coagulation studies, and serum and urine myoglobin levels until they have remained normal for 24 hours. • Instruct the patient and family about testing for MH risk. • Refer the patient and family to the Malignant Hyperthermia Association of the United States at (800) 986-4287 or www.mhaus.org. • Report the incident to the North American Malignant Hyperthermia Registry at the Malignant Hyperthemia Association of the United States: (800) 644-9737.
Postop Hand-Off Report
• Type and extent of the surgical procedure • Type of anesthesia and length of time the patient was under anesthesia • Allergies (especially to latex or drugs) • Any health problems or pathologic conditions • Status of vital signs, including temperature and oxygen saturation • Type and amount of IV fluids and drugs administered • Estimated blood loss (EBL) • Any intraoperative complications, such as a traumatic intubation • *Primary language*, any sensory impairments, any communication difficulties • *Special requests* that were verbalized by the patient preoperatively • Preoperative and intraoperative respiratory function and dysfunction • Location and type of incisions, dressings, catheters, tubes, drains, or packing • *I&O*, including current IV fluid administration and EBL • Prosthetic devices • *Joint or limb immobility* while in the operating room, especially in the older patient • *Other intraoperative positioning* that may be relevant in the postoperative phase • Intraoperative complications, how managed, patient responses (e.g., laboratory values)
