Perioperative Nursing Management
What are some gerontologic considerations related to postoperative management?
1) Delirium 2) Pneumonia 3) Decline in functional ability 4) Exacerbation of comorbid conditions 5) Pressure ulcers 6) Decreased oral intake 7) GI disturbance 8) falls
What is done during the diagnosis stage to optimize patient outcomes during the intraoperative period?
1) Diagnose certain risks: latex, perioperative positioning injury, injury related to anesthesia and surgical procedure, altered sensory perception
What are some local factors that affect wound healing?
1) Edema 2) Inadequate dressing ( too small or tight) 3) Nutritional deficits 4) Foreign bodies 5) Oxygen deficits 6) Drainage accumulation
What are some examples of Anticholinergics?
1) Epinephrine 2) Dopamine 3) norepinephrine 4) formoterol
What are some systemic disorders that affect wound healing?
1) Hemorrhagic shock 2) Acidosis 3) Hypoxia 4) Renal failure 5) Hepatic disease 6) Sepsis 7) Immunosuppressed state
What are the disadvantages of local anesthesia?
1) High preoperative levels of anxiety 2) Impractical due to number of injections 3) Burning sensation
What are the nursing interventions to reduce risk factors?
1) Identify patients at risk 2) Recognize signs and symptoms 3) Have appropriate medication and equipment on hand 4) Follow protocol
What are some nursing responsibilities during the Preadmission Testing (PAT) phase?
1) Initiates initial preoperative assessment 2) Initiates teaching appropriate to patient's needs 3) Involves family in interview 4) Verifies completion of preoperative diagnostic testing 5) Verifies understanding of surgeon-specific preoperative orders 6) Discusses, reviews advanced-directive document 7) Begins discharge planning by assessing patient's need for postoperative transportation, care
What is done during the intervention stage to optimize patient outcomes during the intraoperative period
1) Introduce yourself in a warm, friendly way 2) Verify details and provide information 3) Use basic communication skills to reduce anxiety 4) Pay attention to physical comfort 5) Notify them of how long procedure will take 6) Monitor and manage for complications
What is a registered nurse first assistant?
A member of the OR team whose responsibilities may include handling tissue, providing exposure at the operative field, suturing, and maintaining homeostasis
What is the Postoperative Phase?
Begins with the admission of the patient to the PACU and ends with a follow-up evaluation in the clinical setting or home
What is the role of the nurse in ensuring patient safety during the intraoperative period?
Being alert to and reporting changes in vital signs, cardiac dysrhythmias, symptoms of nausea and vomiting, anaphylaxis, hypoxia, hypothermia, and malignant hyperthermia and assisting with management
Protecting Patient from Injury- Intervention stage
• Patient identification • Correct informed consent • Verification of records of health history, exam • Results of diagnostic tests • Allergies (include latex allergy) •Monitoring, modifying physical environment •Safety measures (grounding of equipment, restraints, not leaving a sedated patient) •Verification, accessibility of blood
Positioning Factors to consider- Intervention stage
• Patient should be as comfortable as possible • Operative field must be adequately exposed • Position must not obstruct/compress respirations, vascular supply, or nerves • Extra safety precautions for older adults, patients who are thin or obese, and anyone with a physical deformity • Light restraint before induction in case of excitement
What are some common postoperative thromboembolic problems?
1) DVT 2) Pulmonary embolism
What are some common postoperative urinary problems?
1) Acute urine retention 2) UTI
What are some variables that affect wound healing?
1) Age of patient 2) Handling of tissues 3) Hemorrhage
What are the principles of surgical asepsis?
1) All material within sterile field must be sterile 2) Gowns sterile in front from chest to level of sterile field, sleeps from 2 inches above elbow to cuff 3) Only top of draped tables considered sterile 4) Items dispensed by methods to preserve sterility 5) Movements of surgical team are from sterile to sterile, from unsterile to unsterile only 6) Movement at least 1 foot distance from sterile field must be maintained 7) When sterile barrier is breached, area is contaminated 8) Every sterile field is constantly maintained, monitored 9) Sterile fields prepared as close to time of use
What are the adverse effects of surgery and anesthesia?
1) Allergic reactions, drug toxicity or reactions 2) Cardiac dysrhythmias 3) CNS changes, oversedation, undersedation 4) Trauma: laryngeal, oral, nerve, skin, including burns 5) Hypotension 6) Thrombosis
What are the surgical risk factors related to age specific populations?
1) Anesthesia awareness 2) Nausea and vomiting 3) Anaphylaxis 4) Hypoxia 5) Hyperthermia 6) Malignant Hyperthermia 7) Disseminated intravascular coagulation 8) Infection
What are the assessment parameters appropriate for the early detection of postoperative complications?
1) Assess breathing, give O2 as needed 2) Monitor all vitals, assess skin 3) Assess surgical site, monitor for drainage 4) Assess neurological function 5) Assess OPQRST for pain 6) Administer pain meds as needed 7) Place call light, emesis basin, ice chips, and bedpan/urinal within reach 8) Make patient comfortable 9) Assess IV sites for appropriate flow rate and reactions 10) Monitor patient output 11) Deep breathing and leg exercises 12) Provide information to patient and family
What are the responsibilities of the post anesthesia care nurse in the prevention of immediate postoperative complications?
1) Assessing the patient 2) Maintaining patient airway 3) Assessing for hypotension and shock 4) Assessing for hemorrhage 5) Assessing for hypertension and dysrhythmias 6) Relieving pain and anxiety 7) Controlling nausea and vomiting
What are some common postoperative respiratory problems?
1) Atelectasis 2) pneumonia 3) pulmonary embolism 4) aspiration
What are the nursing responsibilities in regards to regional anesthesia?
1) Avoid careless conversation, unnecessary noises, unpleasant odors 2) Avoid saying diagnosis
What are some examples of Antihistamines?
1) Azelastine 2) Loratadine 3) Promethazine hydrochloride 4) Diphenhydramine hydrochloride
What are some common postoperative skin/wound problems?
1) Breakdown 2) infection 3) evisceration 4) Delayed healing 5) Hemorrhage 6) Hematoma
Describe the gerontologic considerations related to preoperative management
1) Cardiac and circulatory compromise 2) Respiratory compromise 3) Renal function 4) Confusion 5) Fluid & electrolyte imbalances 6) Skin 7) Comorbidities 8) Altered sensory 9) Mobility restrictions
What are some common postoperative GI problems?
1) Constipation 2) Paralytic ileus 3) Bowel obstruction
What are the nursing responsibilities in regard to general anesthesia?
1) Continue to monitor level of consciousness (GCS score), cardiac rhythm, respiratory status, vital signs 2) Maintain safe environment for older adult clients due to sensory limitations 3) Monitor tubes, catheters, IV'S, 4) Notify provider of any abnormalities
What are some medications that affect wound healing?
1) Corticosteroids 2) Anticoagulants 3) Broad spectrum and narrow spectrum antibiotics 4) Patient overactivity
What are the legal and ethical considerations related to obtaining informed consent for surgery?
1) It should explain the procedure and the risks 2) It should have benefits and alternate procedures identified 3) It should answer any patient questions about the procedure 4) It should contain instructions that the patient may withdraw consent 5) A statement informing the patient if the protocol differs from customary procedure
What are the side effects opioid agonists?
1) Lightheadedness 2) Dizziness 3) Sedation 4) Sweating 5) Confusion 6) Disorientation 7) Orthostatic Hypotension 8) Respiratory Depression 9) Urinary Retention
Describe the immediate preoperative preparation of the patient
1) Making sure patient changes into a hospital gown with the back open 2) For patients with long hair, make sure it is pulled away from face and covered with disposable cap 3) Making sure no jewelry is worn for surgery 4) All valuable articles are given to a family member 5) Making sure patient voids before surgery
What are the disadvantages of regional anesthesia?
1) Not injecting medicine in to correct area- spinal 2) Paralysis of respiratory muscles- spinal 3) Headache- spinal
Describe a comprehensive preoperative assessment to identify surgical risk factors.
1) Nutritional, fluid status - malnutrition/obesity 2) Dentition 3) Drug or alcohol use 4) Respiratory status - Resp rate, lung sounds, clubbing 5) Cardiovascular status - BP, apical, peripheral pulses 6) Hepatic, renal function - Urinary problems 7) Endocrine function - Glucose levels 8) Immune function - allergies 9) Drug history - prescription, OTC, herbal, and recreational use 10) Psychosocial factors 11) Spiritual, cultural beliefs 12) Musculoskeletal - joints, movement 13) Signs of abuse
What are some health factors that affect patients preoperatively?
1) Obesity 2) Nutritional deficits 3) Anxiety 4) History of smoking 5) Hearing/vision impairment
What are some examples of opioid agonists?
1) Oxycodone 2) Fetanyl 3) Methadone 4) Oxycodone with acetaminophen
What are the side effects of using Anticholinergics?
1) Palpitations 2) Tachycardia 3) Dizziness 4) Tremors 5) Orthostatic Hypotension
What is done during the evaluation stage to optimize patient outcomes during the intraoperative phase?
1) Patient exhibits low level of anxiety while awake during intraoperative phase 2) Has no symptoms of latex allergy 3) Remains free of preoperative positioning injury 4) Experiences no unexpected threats to safety 5) Has dignity preserved throughout OR experience 5) Is free of complications or experiences successful management of adverse effects of surgery and anesthesia should they occur
What are the advantages of regional anesthesia?
1) Patient is awake and aware of surroundings 2) Absence of headache when given epidural anesthesia 3) Extensive conduction nerve block to lower extremities, perineum, and lower abdomen- spinal
What are the nursing implications of opioid agonists?
1) Perform a neurologic assessment on patient 2) Check for prior patient use of analgesics 3) Perform a pain assessment before administration of an opiate agonist and at appropriate intervals during therapy
What are the 3 phases of preoperative patient care?
1) Preoperative 2) Intraoperative 3) Postoperative
Describe preoperative nursing measures that decrease the risk for infection and other postoperative complications?
1) Prepping the skin 2) Managing nutrition and fluids 3) Prepping the bowel 4) Maintaining patient safety
What is done during the planning stage to optimize patient outcomes during the intraoperative period?
1) Reduce anxiety 2) Absence of latex exposure 3) Absence of positioning injuries 4) Freedom from injury 5) Maintenance of patient dignity 6) Absence of all complications
What are the nursing implications of Antihistamines?
1) Review patient history for glaucoma, asthma, and prostatic hyperplasia 2) Make sure patient is monitored with drowsiness
What are the side effects of Antihistamines?
1) Sedative effects 2) Cognitive impairment 3) Drying effects 4) Blurred vision 5) Urinary retention 6) Dry mouth
What are some common postoperative cardiovascular problems?
1) Shock 2) Thrombophlebitis
What are the advantages of local anesthesia?
1) Simple, economical, and nonexplosive 2) Minimal equipment needed 3) Brief recovery 4) Avoid effects of general anesthesia 5) Ideal for short, minor procedures
What are some common postoperative neurologic problems?
1) Stroke 2) Delirium
What are some wound stressors that affect wound healing?
1) Vomiting 2) Valsalva maneuver 3) Heavy coughing 4) Straining
What are some common postoperative functional problems?
1) Weakness 2) Fatigue 3) Functional decline
What is the management for DVT and Pulmonary Embolism?
1) low dose heparin 2) low dose warfarin
What does the scrub nurse do?
An RN, LPN, or Surg Tech who scrubs and dons sterile surgical attire, prepares instruments and supplies, and hands them to the surgeon during the procedure
What are the uses of regional anesthesia?
An anesthetic agent injected in a local area with nerves so that the regions supplied by these nerves are anesthetized
What is the management for infection (wound sepsis) ?
Antimicrobial therapy and a wound care regimen
What are the actions of Antihistamines?
Compete for H1 receptor sites in patient's arterioles, capillaries, and secretory glands
What is the postoperative care of the ambulatory surgery patient?
Conditions of these patients do not need close monitoring; Patients are given verbal and written instructions about home recovery
What is the postoperative care of hospitalized surgery patients?
Conditions of these patients require close monitoring and over night hospital stay for multiple needs
What does the circulating nurse do?
Coordinates and documents patient care in the OR
Describe the interdisciplinary approach to the care of the patient during surgery
Involves the circulating nurse, scrub nurse, surgeon, registered nurse first assistant, anesthesiologist
What is done during assessment to optimize patient outcomes during the intraoperative period?
Obtain objective and subjective data
Describe the gerontologic considerations related to the intraoperative management
Patients are at a higher risk for complications due to increased likelihood of coexisting conditions, aging heart and pulmonary systems, decreased homeostatic mechanisms, and changes in response to drugs, and anesthetic agents due to aging changes, changes in body composition of fat and water
What does the surgeon do?
Performs the procedure
What is the management for hematoma?
Physician removes sutures to expose clot, nurse packs wound with gauze
What does the anesthesiologist do?
Physician trained to administer anesthesia and monitor patient's conditions throughout the procedure
What is the management for wound dehiscence and evisceration?
Placing an abdominal binder for support and a primary dressing
What are the advantages of general anesthesia?
Rapid onset
What are the actions of Anticholinergics?
Stimulates beta-1 and beta-2 receptors in the nervous system
What are the actions of opioid agonists?
Stimulates opiate receptors in the CNS to relieve severe pain without loss of consciousness
What are the uses of local anesthesia?
To numb tissues at planned incision sites (Combined with regional block by injecting around the nerves immediately supplying area or combined with epinephrine to constrict blood vessels)
What are the uses general anesthetic agents?
Used to put patient in an unarousable state, not even to painful stimuli, requiring ventilation during surgery
What are the disadvantages of general anesthesia?
Ventilation assistance, muscle weakness, coma, decreased cardiac output
What is the Preoperative Phase?
When the decision to proceed with surgical intervention is made and ends with the transfer of the patient on to the operating room bed
What is the Intraoperative Phase?
When the patient is transferred onto the OR bed and ends with admission to the PACU
Intervention Continued
• Reducing anxiety • Reducing latex exposure • Preventing positioning injuries, refer to Figure 18-5 • Protecting patient from injury • Serving as patient advocate • Monitoring, managing potential complications
