Ch. 14/15/16/30 Peri-op and Post-op care

nursing interventions for atelectasis

-positioning the patient in semi-Fowler's position, administering oxygen, and administering analgesics for pain. -For a sudden onset, notify the surgeon immediately and call the medical intervention team

major surgery

--> may be elective, urgent, or emergency • To preserve life • To remove or repair a body part • To restore function • To improve or maintain health Carotid endarterectomy, cholecystectomy, nephrectomy, colostomy, hysterectomy, radical mastectomy, amputation, trauma repair, CABG

Preoperative Instructions to Prevent Postoperative Complications

-->EDUCATION STARTED AS SOON AS POSSIBLE Diaphragmatic Breathing Diaphragmatic breathing refers to a flattening of the dome of the diaphragm during inspiration, with resultant enlargement of the upper abdomen as air rushes in. During expiration, the abdominal muscles contract. 1.Practice in the same position you would assume in bed after surgery: a semi-Fowler position, propped in bed with the back and shoulders well supported with pillows. 2.Feel the movement with your hands resting lightly on the front of the lower ribs and fingertips against the lower chest. 3.Breathe out gently and fully as the ribs sink down and inward toward midline. 4.Then take a deep breath through your nose and mouth, letting the abdomen rise as the lungs fill with air. 5.Hold this breath for a count of five. 6.Exhale and let out all the air through your nose and mouth. 7.Repeat this exercise 15 times with a short rest after each group of five. 8.Practice this twice a day preoperatively. Coughing 1.Lean forward slightly from a sitting position in bed, interlace your fingers together, and place your hands across the incision site to act as a splint for support when coughing. 2.Breathe with the diaphragm as described under "Diaphragmatic Breathing." 3.With your mouth slightly open, breathe in fully. 4."Hack" out sharply for three short breaths. 5.Then, keeping your mouth open, take in a quick deep breath and immediately give a strong cough once or twice. This helps clear secretions from your chest. It may cause some discomfort but will not harm your incision. Leg Exercises 1.Lie in a semi-Fowler position and perform the following simple exercises to improve circulation. 2.Bend your knee and raise your foot—hold it a few seconds, then extend the leg and lower it to the bed. 3.Do this five times with one leg and then repeat with the other leg. 4.Then trace circles with the feet by bending them down, in toward each other, up, and then out. 5.Repeat these movements five times. Turning to the Side 1.Turn on your side with the uppermost leg flexed most and supported on a pillow. 2.Grasp the side rail as an aid to maneuver to the side. 3.Practice diaphragmatic breathing and coughing while on your side. Getting Out of Bed 1.Turn on your side. 2.Push yourself up with one hand as you swing your legs out of bed.

nursing interventions for pneumonia

-positioning the patient in semi-Fowler's or Fowler's position -encouraging the use of incentive spirometry -promoting ambulation -administering oxygen -administering medications (e.g., antibiotics, expectorants, analgesics) -providing frequent oral hygiene -ensuring rest and comfort.

Preadmission testing (PAT)

-A series of diagnostic tests done before surgery to establish the patient's health status and identify any potential problems that may occur during surgery. -admission data such as patient demographics, health history, and other information pertinent to the surgical procedure (i.e., appropriate consent forms, diagnostic and laboratory tests) -what to expect on the day of surgery and receive answers to questions they may have

moderate sedation/analgesia

-Conscious sedation or procedural sedation. -Used for short term and minimally invasive procedures. -patient maintains cardiorespiratory function and can respond to verbal commands -decrease in anxiety and discomfort/pain with some degree of amnesia

general anesthesia

-IV or inhalation of anesthics -typically a combo of both desired actions: -loss of consciousness -amnesia (short-term loss of memory) -analgesia (the brain does not respond to pain signals) -relaxed skeletal muscles -depressed reflexes

standard universal protocol to prevent wrong-site, wrong-procedure, and wrong-person surgery

-Preoperative patient identification verification process -Marking the operative site -Final verification just prior to beginning the procedure, referred to as the time-out

when preparing the patient psychologically through teaching...

-Teaching about postoperative activities is implemented in the preoperative phase

regional anesthesia

-Temporary interruption of nerve conduction, is produced by injecting an anesthetic solution near the nerves to be blocked. -patient remains awake -reflexes may be lost

transplantation surgery

-To replace organs or structures that are diseased or malfunctioning. e.g., Kidney, liver, cornea, heart, joints

nursing interventions for thrombophlebitis and thromboembolism

-administering medications (e.g., low-molecular-weight heparin or low-dose unfractionated heparin) -correctly applying graduated compression stockings -IPCDs/venous foot pumps -increasing mobility

advanced directives

-allows patients to give directions to health care providers about treatment choices in circumstances in which the patient may no longer be able to provide that direction. There are two types: Living Will and Durable Power of Attorney

nursing interventions for hemorrhage

-applying a pressure dressing to the bleeding site -calling the medical intervention team -notifying the surgeon immediately -being prepared to have the patient return to the OR if bleeding cannot be stopped.

nursing interventions to prevent surgical site complications

-assessing vital signs (especially for fever) -maintaining hydration -maintaining nutritional status -encouraging a diet high in proteins, carbohydrates, calories, and vitamins -using proper hand hygiene -following aseptic technique when changing dressings at the surgical site and exit sites for tubes and drains

when preparing the patient psychologically through communicating...

-avoid false reasurance -establish a supportive and trusting nurse-patient relationship -facilitate psychological safety and security

local anesthesia

-causes the loss of sensation in a limited area by injecting an anesthetic solution near that area -minor, short-term surgical, or diagnostic procedures such as tissue biopsy -epinephrine minimizes bleeding and prolongs anasthetic effect

reduce anxiety and decreasing fear

-discuss with patient to identify the source of fear -patient benefits from knowing when family and friends will be able to visit after surgery and that a spiritual advisor will be available if desired -areful attention should be placed on patients who experience a delay in surgery

nursing interventions for shock

-include calling for the medical intervention team and notifying the surgeon immediately -establishing and maintaining the airway -placing the patient in a flat position with the legs elevated 30 to 45 degrees -administering oxygen -monitoring vital signs, hematocrit, and blood gas results -maintaining body warmth with covers -administering medications

nursing interventions pulmonary embolism

-notifying the health care provider immediately -calling the medical intervention team -maintaining the patient on bed rest in the semi-Fowler's position -assessing vital signs frequently -administering oxygen -administering medications (e.g., anticoagulants, analgesics) -instructing the patient to avoid Valsalva's maneuver (forced exhalation against a closed glottis, such as straining to have a bowel movement) to prevent increased intrathoracic pressure and, possibly, increased emboli.

topical anesthesia

-numbs only the tissue surface and is applied as a liquid, ointment, or spray

Throughout surgery, the perioperative nurse documents on the intraoperative record...

-ongoing patient assessment -item counts (soft goods, sharps, instruments) -monitoring data (e.g., vital signs, urine output, blood loss, pulse oximetry results, body temperature) -positioning -medications -dressings and drains -specimens -equipment used (electrosurgery unit and settings, ultrasound, video, stirrups for positioning) -responses to care

preparing the patient physically for surgery

-skin is cleaned at the operative site with an antibacterial soap or solution to remove bacteria --> can be done in the shower or bath -Leave hair at the surgical site in place if possible -elimination is no longer a routine process -If the patient is scheduled for surgery of the lower gastrointestinal tract, a prescribed bowel prep and cleansing enema may be prescribed. -If the patient is scheduled for surgery of the lower gastrointestinal tract, a prescribed bowel prep and cleansing enema may be prescribed. -Focused assessment and preadmission testing that includes a hemoglobin and hematocrit allow the provider to: (1) address anemia prior to surgery with iron and erythropoietin, (2) discontinue anticoagulants and antiplatelet agents that may interfere with clotting, and (3) collect autologous (self-donated) blood -NPO 8 hours before surgery (may drink clear liquids 2 hours before)

Once the patient transfers from the stretcher to the OR bed...

-the patient is identified again with the operative team using at least two identifiers (such as name, birth date). -The patient is then anesthetized, positioned, prepped, and draped. -The perioperative nurse assesses the patient and reviews preoperative data, paying particular attention to factors that increase surgical risk. -To maintain patient safety, the nurse also assesses the patient during positioning, and monitors supplies used. q's on intraop care ⚫What's sterile what is unsterile? ⚫Who is who in the OR? ⚫Positioning? ⚫Anything else you don't quite understand?

3 phases of general anesthesia

1. Induction begins with administration of the anesthetic agent and continues until the patient is ready for the incision. 2. Maintenance continues from this point until near the completion of the procedure. 3. Emergence starts as the patient begins to awaken from the altered state induced by the anesthesia and usually ends when the patient is ready to leave the OR; the length of time depends on the depth and length of anesthesia.

3 postoperative phases

1. providing patient care from a totally anesthetized state to one requiring less acute nursing interventions 2. preparing the patient for self-care or family care or for care in a phase III extended care environment 3. providing ongoing care for patients requiring extended observation or intervention after transfer or discharge from phase I or II

providing preop patient care

5. Close the curtains around the bed and close the door to the room, if possible. Explain what you are going to do and why you are going to do it to the patient and significant other. Place necessary supplies on the bedside stand, overbed table, or other surface within easy reach. 6. Explore the psychological needs of the patient and family related to the surgery. a. Establish a therapeutic relationship, encouraging the patient to verbalize concerns or fears. b. Use active listening skills, answering questions and clarifying any misinformation. c. Use touch, as appropriate, to convey genuine empathy. d. Offer to contact spiritual counselor (e.g., priest, minister, rabbi) to meet spiritual needs. 7. Identify learning needs of patient and family. Ensure that the informed consent of the patient for the surgery has been signed, timed, dated, and witnessed. Inquire if the patient has any questions regarding the surgical procedure. Check the patient's record to determine if an advance directive has been completed. If an advance directive has not been completed, discuss with the patient the possibility of completing it, as appropriate. If patient has had surgery before, ask about this experience. 8. Teach deep-breathing exercises. 9. Teach coughing and splinting. 10. Teach use of incentive spirometer, as prescribed or indicated. 11. Teach leg exercises, as appropriate. 12. Teach about early ambulation, as appropriate. 13. Assist the patient in putting on graduated compression stockings. Demonstrate how the pneumatic compression device operates. 14. Teach about turning in the bed. a. Instruct the patient to use a pillow or bath blanket to splint where the incision will be. Ask the patient to raise his or her left knee and reach across to grasp the right side rail of the bed). If the patient is turning to the left side, he or she will bend the right knee and grasp the left side rail. b. When turning the patient onto the right side, ask the patient to push with bent left leg and pull on the right side rail (Figure 2). Explain to the patient that you will place a pillow behind his/her back to provide support, and that the call bell will be placed within easy reach. c. Explain to the patient that position change is recommended every 2 hours. 15. Provide individualized, developmentally appropriate teaching about pain management options, plans and goals. a. Discuss past experiences with pain and interventions that the patient has used to reduce pain. b. Discuss the availability of analgesic medication postoperatively. c. Discuss the use of PCA, as appropriate. d. Explore the use of other alternative and nonpharmacologic methods to reduce pain, such as position change, massage, relaxation/diversion, guided imagery, and meditation. 16. Review equipment that may be used after surgery. a. Show the patient various equipment, such as IV infusion devices, electronic blood pressure cuff, tubes, urinary catheters, and surgical drains. 17. Provide skin preparation. a. Ask the patient to bathe or shower with the antibacterial soap or solution. Remind the patient to clean the surgical site. 18. Provide teaching about and follow dietary/fluid restrictions. Explain to the patient that both food and fluid will be restricted before surgery to ensure that the stomach contains a minimal amount of gastric secretions. This restriction is important to reduce the risk of aspiration. Emphasize to the patient the importance of avoiding food and fluids during the prescribed time period, because failure to adhere may necessitate cancellation of the surgery. 19. Provide intestinal preparation, as appropriate. In certain situations, such as surgery of the lower gastrointestinal tract, the bowel will need to be prepared by administering enemas or laxatives. a. As needed, explain the purpose of enemas or laxatives before surgery. If the patient will be administered an enema, clarify the steps as needed. 20. Check administration of regularly scheduled medications. Review with the patient routine medications, over-the-counter medications, and herbal supplements that are taken regularly. Check the medical orders and review with the patient which medications he or she will be permitted to take the day of surgery. 21. Provide information to the patient and family regarding timing of surgical events and potential sensations that may be experienced. Explain to patients and their families how long the surgery and postanesthesia care will last, as well as what will be done before, during, and after surgery (e.g., procedures, medications, equipment). Explain to patients that they may not drive themselves home or take public transportation alone if they have had any anesthesia or sedation.

Providing Postop Care

5. Place patient in safe position (semi- or high Fowler's or side-lying). Note level of consciousness. 6. Obtain vital signs. Monitor and record vital signs frequently. Assessment order may vary, but usual frequency includes taking vital signs every 15 minutes the first hour, every 30 minutes the next 2 hours, every hour for 4 hours, and finally every 4 hours. 7. Assess the patient's respiratory status. Measure the patient's oxygen saturation level. If oxygen is ordered, ensure accurate delivery device and flow rate. 8. Assess the patient's cardiovascular status. 9. Assess the patient's neurovascular status, based on the type of surgery performed. 10. Provide for warmth, using heated or extra blankets, or forced-air warming device as necessary. Assess skin color and condition. 11. Put on gloves. Assess the surgical site. Check dressings for color, odor, presence of drains, and amount of drainage. Mark the drainage on the dressing by circling the amount, and include the time. Assess dependent areas, such as turning the patient to assess visually under the patient, for bleeding from the surgical site. 12. Verify that all tubes and drains are patent and the equipment is working; note the amount of drainage in collection device. If an indwelling urinary catheter is in place, note urinary output. 13. Verify and maintain IV infusion at prescribed rate. 14. Assess for pain. Check health record to verify if analgesic medication was administered in the PACU. Administer analgesics as indicated, prescribed/ordered and appropriate. If the patient has been instructed in the use of PCA for pain management, review its use. Institute nonpharmacologic pain management interventions as appropriate and indicated. 15. Assess for nausea and vomiting. Administer antiemetic medication as indicated, prescribed/ordered, and appropriate. 16. Provide for a safe environment. Keep bed in low position with side rails up, based on facility policy. Have call bell within patient's reach. 17. Remove PPE, if used. Perform hand hygiene. Ongoing Care 18. Promote optimal respiratory function. a. Assess respiratory rate, depth, quality, color, and capillary refill. Ask if the patient is experiencing any difficulty breathing. b. Assist with coughing and deep-breathing exercises. c. Assist with incentive spirometry, as indicated/ordered. d. Assist with early ambulation. e. Provide frequent position changes. f. Administer oxygen, as ordered. g. Monitor pulse oximetry. 19. Promote optimal cardiovascular function: a. Assess apical rate, rhythm, and quality and compare with peripheral pulses, color, and blood pressure. Ask if the patient has any chest pains or shortness of breath. b. Provide frequent position changes. c. Assist with early ambulation. d. Apply graduated compression stockings or pneumatic compression devices, if ordered and not in place. If in place, assess for integrity. e. Provide leg and range-of-motion exercises if not contraindicated. 20. Promote optimal neurologic function: a. Assess level of consciousness, movement, and sensation. b. Determine the level of orientation to person, place, and time. c. Test motor ability by asking the patient to move each extremity. Anesthesia alters motor and sensory function. d. Evaluate sensation by asking the patient if he or she can feel your touch on an extremity. 21. Promote optimal renal and urinary function and fluid and electrolyte status. Assess intake and output, evaluate for urinary retention and monitor serum electrolyte levels. a. Promote voiding by offering bedpan/bedside commode, or assistance to bathroom at regular intervals, noting the frequency, amount, and if any burning or urgency symptoms. b. Monitor urinary catheter drainage if present. c. Measure intake and output. 22. Promote optimal gastrointestinal function and meet nutritional needs: a. Assess abdomen for distention and firmness. Ask if patient feels nauseated, any vomiting, and if passing flatus. b. Auscultate for bowel sounds. c. Assist with diet progression; encourage fluid intake; monitor intake. d. Medicate for nausea and vomiting, as ordered. 23. Promote optimal wound healing. a. Assess condition of wound for presence of drains and any drainage. b. Use surgical asepsis for dressing changes and drain care. c. Inspect all skin surfaces for beginning signs of pressure injury and use pressure-relieving supports to minimize potential skin breakdown. 24. Promote optimal comfort and relief from pain. a. Assess for pain (location and intensity using pain scale). b. Provide for rest and comfort; provide extra blankets, as needed, for warmth. c. Administer analgesics, as needed, and/or initiate nonpharmacologic methods, as appropriate. 25. Promote optimal meeting of psychosocial needs: a. Provide emotional support to patient and family, as needed. b. Explain procedures and offer explanations regarding postoperative recovery, as needed, to both patient and family members.

Nursing Interventions to Facilitate Postoperative Coping and Adaptation

Accept each patient as a unique person. Identify through verbal and nonverbal cues patients who are at risk for alteration in self-concept. The risk is increased if the patient has little support from others, a visible alteration, or an alteration that will seriously affect functional ability. Allow time for patients and families to verbalize their feelings about the alteration, and do not assume that all patients will have problems. Identify and support strengths and effective coping mechanisms. Encourage the patient and family to be part of goal setting and decision making throughout the surgical experience. Provide teaching and honest information to the patient and family about all aspects of care. Work collaboratively with other members of the health care team to provide referrals and resources as necessary to meet physical, psychological, and spiritual needs.

epidural anesthesia

injection of the anesthetic through the intervertebral spaces, usually in the lumbar region (although it may also be used in the thoracic or cervical regions). It is used for surgeries of the chest, abdomen, pelvis, and legs; epidurals are also commonly used in childbirth.

adverse effects of surgery and anesthesia

Airway management, use of oral airways to maintain a patent airway in a sedated patient until the patient can manage their own airway and secretions. Prevention of nerve injury, and pressure injuries with the use of gel padding of patient. Burn prevention through the use of grounding plates when electrocautery is used. Closed circuits for the anesthetic gasses as they are highly flammable Fire blankets. Hypotension r/t blood loss or hypovolemia, fluid replacement based on many factors including patient PMH, type of surgery, type of anesthesia. Vasopressors may be required to support the patient's BP post op. Thrombosis- prevention with TED and SCD stockings.

Preoperative medications that might be prescribed are as follows:

Sedatives, such as diazepam, midazolam, or lorazepam, to alleviate anxiety and decrease recall of events related to surgery Anticholinergics, such as atropine and glycopyrrolate, to decrease pulmonary and oral secretions and to prevent laryngospasm Narcotic analgesics, such as morphine, to facilitate patient sedation and relaxation and to decrease the amount of anesthetic agent needed Neuroleptanalgesic agents, such as fentanyl citrate-droperidol, to cause a general state of calmness and sleepiness Histamine-2 receptor blockers, such as cimetidine and ranitidine, to decrease gastric acidity and volume

intraoperative complications

Anesthesia awareness-neurologic monitoring, muscle relaxants, and a combination of drugs to help prevent this. Death within 24 hours of surgery or in the OR is considered a coroner's case to determine the cause of death. Pre medication to prevent N/V, use of an NGT to drain stomach contents. NPO status helps to prevent this. Anaphylaxis preplanning and pretreatment to prevent risk to the patient. Example iodine allergy. Iodine is used in some skin preps Betadine, or IV contrast dye. ETCo2 - monitoring to decrease hypoxia, direct visualization for tube placement and ETT tube confirmation with a CO2 detector, assess breath sounds. Chest x-rays for patients who remain intubated to verify ETT tube placement. Aspiration pneumonia - management of oral/gastric secretions, suction equipment readily available. Bronchospasm- COPD/smoke pts high risk, pretreatment with bronchodilators, steroids, treatment with lidocaine, epinephrine nebulizer, AMBU bag, PEEP. Laryngospasm - upper airway and treatment is much the same as a bronchospasm. Pulmonary edema- fluid overload, or breathing against a closed glottis, upper airway obstruction. Inadequate ventilation, poor depth, of ventilation, may need to reverse the muscle relaxant. Sugammadex - rocuronium, narcan-opioid antagonist, flumazinil- benzodiazapines. Gerontologic considerations include smaller doses to achieve the therapeutic effect, delayed clearance and metabolism of drugs, avoid drugs that cause retrograde amnesia-versed, especially if there is underlying pathology. Hypothermia- due to the OR temperature, environment, exposure of the patient, surgeons and equipment. Prevent cardiac complications-PVCs, cardiac irritability, prolongs anesthetic metabolism, delays and emergence for the patient. The use of Bair huggers, which blows warmed air over the patient helps prevent this. Malignant Hyperthermia- usually a family history or could be unknown, avoid certain triggering agents such as succinylcholine, and some anesthetic gases, isoflurane, halothane, desoflurane, sevoflurane, reversal is Dantrolene. It is a life threatening emergency. Early recognition is key. s/s increased ETCo2, muscle spasm/tetany, tachycardia, sweating, metabolic and respiratory acidosis. If left untreated the patient will progress to cardiac arrest. MHaus is a marvelous resource and has a hotline to call during an MH emergency. A facility with an OR may perform drills to educate staff and maintain readiness. Late s/s cardiac arrhythmias, cardiac arrest, DIC, myoglobinuria, elevated creatine phosphokinase, elevated temperature, hypocalcemia, mottled cyanosis. Infection- prevention is key, use of SCIP (Surgical Care Improvement, Project), give antibiotics within 1 hr of surgical incision, limited use of antibiotics and correct type for the surgery, d/c within 24 hrs. The use of clippers not razors for hair removal, and CHG wipes to decrease bacteria/viral load to prevent post op infection. BS control protocol, Normothermia measures (rewarming), VTE prophylaxis (prevents DVT), limited use of urinary catheters and early removal post op. s/s elevated ETCo2, elevated temperature, tachypnea, tachycardia.

drugs that increase surgical risk

Anticoagulants (may precipitate hemorrhage) Diuretics (may cause electrolyte imbalances, with resulting respiratory depression from anesthesia) Tranquilizers (may increase the hypotensive effect of anesthetic agents) Adrenal steroids (abrupt withdrawal may cause cardiovascular collapse in long-term users) Antibiotics in the mycin group (when combined with certain muscle relaxants used during surgery, may cause respiratory paralysis)

Nursing Interventions to Prevent or Monitor Postoperative Cardiovascular Complications

Assess and document vital signs as ordered and as the patient's status dictates, using preoperative assessments as a baseline. Provide covers, forced warm air, or other warming device or techniques as necessary to prevent shivering and hypothermia. Maintain fluid balance. Maintain accurate intake and output. Monitor rate, type, and access site of IV fluids. Assess skin turgor and hydration of mucous membranes. Monitor amount, color, and consistency of wound drainage (dressings and drains or tubes). Implement leg exercises and turning in bed every 2 hours. Assist with ambulation—ambulation usually begins the evening of surgery and increases as tolerated; blood pressure and pulse and respiratory rates are used to monitor tolerance. Apply and follow protocols for graduated compression stockings or pneumatic compression devices, if prescribed. Administer anticoagulant medications, if prescribed. Measure bilateral calf and thigh circumference daily. Assess for leg swelling, tenderness or palpable venous cord. Avoid positioning that impedes venous return (e.g., do not mechanically raise the knee portion of the bed or place pillows under the knees).

Preoperative Assessment and Education for Older Adults

Assessment •Assess for allergies and medical comorbidities. •Assess the patient's cognitive and sensory function before the surgeon begins the informed consent process. •Perform a Fall Risk Assessment including the following factors: •History of previous falls •Medication use (e.g., preoperative sedatives) •Level of consciousness (e.g., alert, lethargic) •Ability to follow directions (e.g., cognitive impairment, language barrier) •Sensory impairments (e.g., vision, hearing) •Level of coordination or balance •Toileting needs (e.g., incontinence, frequency, need for assistance) •Presence of external devices (e.g., catheters, drains) •Determine the need for a designated support person or power of attorney to complete the informed consent process. •Review medications to identify potential polypharmaceutical risks to include the following: •Multiple medications •Multiple prescribers •Several filling pharmacies •Too many forms of medications •Over-the-counter medications •Multiple dosing schedules •Document baseline physical assessment parameters, including pain, cardiac rhythm, and oxygen saturation level. •Document a detailed skin assessment with notation of areas of dryness, lesions, or bruising. •Document preoperative fasting status and assess for dehydration, malnutrition, and hypoglycemia. •Perform a psychosocial assessment that addresses fears, anxiety, and feelings of loneliness. •Identify social support to determine whether the patient has home assistance to complete ADLs. Education •Discuss advanced directives and code status to identify the patient's wishes. •Educate the patient about the benefits of controlling pain. •Be prepared to spend additional time, increase the amount of therapeutic touch utilized, and encourage family members to be present to decrease anxiety.

Nursing Assessments and Interventions to Meet Postoperative Elimination Needs

Bowel Elimination Assess for the return of peristalsis by auscultating bowel sounds every 4 hours when the patient is awake. Assess abdominal distention, especially if bowel sounds are not audible or are high pitched (indicative of possible paralytic ileus, which is an absence of intestinal peristalsis). Assess ability to pass flatus and stool. Assist with movement in bed and ambulation to relieve gas pains, a common postoperative discomfort. Encourage food and fluid intake when ordered, especially fruit juices and high-fiber foods. Maintain privacy when patient is using the bedpan, urinal, commode, or bathroom. Administer suppositories, enemas, or medications, such as stool softeners, as prescribed. Urinary Elimination Monitor patterns of intake and output. Assist in assuming normal position to void by using an upright position when on a bedpan and using a bedside commode or bathroom when able, or by assisting the male patient to stand upright to void with a urinal. Assess for bladder distention by palpating above the symphysis pubis if the patient has not voided within 8 hours after surgery or if the patient has been voiding frequently in amounts of less than 50 mL; notify the health care provider of abnormal assessment results. Maintain prescribed intravenous fluid infusion rates. Encourage oral fluid intake when prescribed. Provide privacy when the patient is using bedpan, bedside commode, urinal, or bathroom. Initiate urinary catheterization, if prescribed.

previous surgical complications that should be documented

malignant hyperthermia, latex sensitivity, pneumonia, thrombophlebitis or deep vein thrombosis (DVT)

Warfarin

Can increase the risk of bleeding during the intraoperative and postoperative periods; should be discontinued in anticipation of elective surgery. The surgeon will determine how long before the elective surgery the patient should stop taking an anticoagulant, depending on the type of planned procedure and the medical condition of the patient.

nursing strategies to address age-related changes in perioperative patients

Cardiovascular Decreased cardiac output, stroke volume, and cardiac reserve Decreased peripheral circulation Increased vascular rigidity Obtain and record baseline vital signs. Assess peripheral pulses. Teach leg exercises, turning, and explain the purpose of early ambulation after surgery. Document baseline activity levels and tolerance of fatigue. Monitor fluid administration rate. Allow sufficient time for effects of medications to occur; administer the lowest dose possible of medications. Respiratory Reduced vital capacity Diminished cough reflex Decreased oxygenation of blood Decreased chest expansion and strength of intercostal muscles and diaphragm Obtain and record baseline respiratory depth and rate. Teach coughing and deep-breathing exercises. Teach use of incentive spirometer. Assess color of skin. Explain use of pulse oximeter for monitoring postoperative oxygenation. Central Nervous System Decreased reaction time and coordination Reduced short-term memory Sensory deficits Decreased thermoregulation ability Orient to surroundings. Institute safety measures, such as keeping environment clear of clutter and using a night-light. Allow additional time for teaching, teach-back activities, and questions and answers. Use appropriate measures to conserve body heat. Renal Decreased renal blood flow Reduced bladder capacity Monitor fluid and electrolyte status. Maintain and record intake and output. Provide ready access to toileting. Gastrointestinal Increased gastric pH Prolonged gastric-emptying time Decreased hepatic blood flow and enzyme function Obtain baseline weight. Monitor nutritional status (weight, laboratory data). Observe for prolonged effects of medications. Integumentary Decreased vascularity Decreased skin moisture and elasticity Decreased subcutaneous fat Assess skin status. Monitor fluid status. Pad and protect bony prominences. Monitor skin for pressure areas. Use minimal amounts of tape on dressings and intravenous sites. Encourage active and passive range of motion, with repositioning as needed.

Dexamethasone

Cardiovascular collapse can occur if discontinued suddenly. Therefore, a bolus of corticosteroids may be administered IV immediately before and after surgery.

Pathologic diseases that increase surgical risk

Cardiovascular diseases—such as thrombocytopenia, hemophilia, recent myocardial infarction or cardiac surgery, heart failure, and dysrhythmias—increase the risk for anesthesia complications, including hemorrhage and hypovolemic shock, hypotension, venous stasis, thrombophlebitis/thromboembolism, and over-hydration with IV fluids. Respiratory disorders—such as pneumonia, bronchitis, asthma, emphysema, and chronic obstructive pulmonary diseases—increase the risk for respiratory depression from anesthesia as well as postoperative pneumonia, atelectasis, and alterations in acid-base balance. Kidney and liver diseases influence the patient's response to anesthesia, affect fluid and electrolyte as well as acid-base balance, alter the metabolism and excretion of drugs, and impair wound healing. Endocrine diseases, especially diabetes mellitus, increase the risk for hypoglycemia or acidosis, slow wound healing, and present an increased risk for postoperative cardiovascular complications.

desired postoperative outcomes

Carry out leg (including foot and ankle) exercises every 2 to 4 hours Deep breathe and cough effectively every 2 hours Engage in early ambulation Verbalize decreasing levels of pain Regain and maintain a balanced intake and output Regain normal bowel and bladder elimination Exhibit a healing surgical incision Remain free of infection Verbalize any concerns about appearance of wound Verbalize and demonstrate wound self-care

PROVIDING PREOPERATIVE PATIENT CARE: HOSPITALIZED PATIENT (DAY OF SURGERY)

Check that preoperative consent forms are signed and dated, witnessed, and correct; that advance directives are in the medical record (as applicable); and that the patient's chart is in order. Gather the needed equipment and supplies. Perform hand hygiene. Check vital signs. Notify health care provider of any pertinent changes (i.e., rise or drop in blood pressure, elevated temperature, cough, symptoms of infection). Provide hygiene and oral care. Assess for loose teeth. Verify adherence to food and fluid restrictions before surgery. Instruct the patient to remove all personal clothing, including underwear, and put on a hospital gown. Ask patient to remove cosmetics, jewelry including body piercing, nail polish, and prostheses (e.g., contact lenses, false eyelashes, dentures). Some facilities allow a wedding band to be left in place, depending on the type of surgery, provided it is secured to the finger with tape. If possible, give valuables to a family member or place valuables in an appropriate area, such as the hospital safe if this is not possible. Have patient empty bladder before surgery. Attend to any special preoperative orders, such as starting an IV line. Complete preoperative checklist and record of patient's preoperative preparation. Administer preoperative medication as prescribed by surgeon/anesthesia provider. Raise side rails of bed; place bed in lowest position. Instruct patient to remain in bed or on stretcher. If necessary, a safety belt may be used. Help move the patient from the bed to the transport stretcher if necessary. Reconfirm patient identification and ensure that all preoperative events and measures are documented. Tell the family of the patient where the patient will be taken after surgery and the location of the waiting area where the surgeon will come to explain the outcome of the surgery. After the patient leaves for the OR, prepare the room and make a postoperative bed for the patient. Anticipate any necessary equipment based on the type of surgery and the patient's history.

informed consent components

Description of the procedure or treatment (its name, site, and side if applicable), potential alternative therapies, and the option of nontreatment The underlying disease process and its natural course Name and qualifications of the health care provider performing the procedure or treatment—provide an emphasis on shared decision making between the patient and provider(s) Explanation of the risks (nature, magnitude, probability of the risks) and benefits Explanation that the patient has the right to refuse treatment and that consent can be withdrawn Explanation of expected (not guaranteed) outcome, recovery, and rehabilitation plan and course ⚫Legal mandate ⚫Surgeon explains: procedure, benefits, risks, complications ⚫In writing before non-emergent surgery ⚫Nurse clarifies information and witnesses signature ⚫Consent is valid ONLY when signed before administering psychoactive premedication ⚫Consent accompanies patient to OR Designated interpreter, document the operator number or ID in the medical record. This also includes ASL (American Sign Language). In Loco Parentis- refers to a person in place of the parent, caring for the child, grandparent. Sometimes it is necessary to contact risk management, or an hospital administrator in certain circumstances. Especially if the patient has no next of kin, or is not able to give consent due to mental capacity. This is why advanced directives are so important. Advance Directives are usually suspended for 24 hours after surgery.

Hydrochlorothiazide

During anesthesia, may cause excessive respiratory depression resulting from an associated electrolyte imbalance.

nursing interventions to meet psychological needs of patients having surgery

Establish and maintain a therapeutic relationship, allowing the patient to verbalize fears and concerns. Use active listening skills to identify and validate verbal and nonverbal messages revealing anxiety and fear. Use touch, as appropriate, to demonstrate genuine empathy and caring. Be prepared to respond to common patient questions about surgery, including: Will I lose control of body functions while I'm having surgery? How long will I be in the operating room and PACU? Where will my family be? Will I have pain when I wake up? Will the anesthetic make me sick? Will I need a blood transfusion? How long will it be before I can eat? What kind of scar will I have? When will I be able to be sexually active? When can I go back to work?

IPCDs Nursing Care

Explain the purpose of the device to the patient. Apply the device according to the manufacturer's instructions, making sure that two fingers fit between the leg and the sleeve. Position the tubing so the patient can move about without interrupting the airflow. Remove the sleeves at least once a day for skin care and assessment. Assess the extremities for peripheral pulses, edema, changes in sensation, and movement on a regular schedule. Ensure that all chambers are inflating in proper sequence once per shift.

perioperative physical assessment

General survey Note general state of health. Note body posture and stature. Take and record vital signs. Integumentary system Inspect skin for color, characteristics, and location and appearance of any lesions. Assess skin over bony prominences. Determine skin turgor. Respiratory system Observe chest excursion and diameter and shape of thorax. Auscultate breath sounds. Palpate for any pain or tenderness. Cardiovascular system Inspect for jugular vein distention. Auscultate apical rate, rhythm, and character. Auscultate heart sounds. Inspect for peripheral edema. Palpate strength of peripheral pulses bilaterally. Gastrointestinal system Inquire about time of last intake of fluid or food. Inquire about time of last bowel movement. Inspect abdominal contour. Auscultate bowel sounds. Neurologic system Note orientation, level of consciousness, awareness, and speech. Assess reflexes. Assess motor and sensory ability. Assess visual and hearing ability. Musculoskeletal system Inspect and note joint range of motion. Palpate muscle strength. Assess ability to ambulate.

general coping strategies

Guided Imagery: The patient concentrates on a pleasant experience or restful scene. Distraction: The patient thinks of an enjoyable story or recites a favorite poem or song. Optimistic Self-Recitation: The patient recites optimistic thoughts ("I know all will go well"). Music Therapy: The patient listens to soothing music (an easy-to-administer, inexpensive, noninvasive intervention). Aromatherapy: The patient inhales aromatic oils to trigger emotional and physical relaxation responses through the olfactory system and brain. Reiki: The practitioner places hands over the patient to (theoretically) transfer energy to promote healing and relaxation.

Preoperative nursing care is specific and focused on addressing key aspects of care involving:

Holistic preoperative screening: complete medical, physical, social, psychological, and personal assessments Coordination: collaborate with the entire interprofessional team Communication: promote open, clear communication Patient and family education: provide specific pre- and postoperative instructions Individual patient- and family-centered care: promote empowerment and emotional support/comfort Preoperative contact: engage with the patient prior to surgery for screening and patient preparation, providing last-minute instruction as needed Scheduling: prioritize and communicate surgical scheduling plans

levothyroxine sodium

IV administration may be needed during the postoperative period to maintain thyroid levels.

carbamazepine

IV administration of medication may be needed to keep the patient seizure-free in the intraoperative and postoperative periods.

Preop patient education

Inpatient/outpatient surgery- Many surgeries that patients were hospitalized for many days now are discharged to home the same day. In order to do this there is much preplanning and teaching done prior to surgery. Hysterectomy, Cholecystectomy, TKA are several examples. Many people have an image of minimally invasive surgery, that is drive thru surgery. You pull up to the window place your order (have your surgery), pick it up at the next window (wake up) and go home. However it is still surgery, painful and it is a big surgery done through itty, bitty little holes. When I first graduated nursing school cholecystectomy patients were hospitalized for 5-10 days, had an NGT, and a t-tube in the bile duct. Now they have 3 or 4 puncture sites and go home the same day. This is a remarkable feat but it still is surgery. Use teach-back method to gauge patient/family understanding. Tell the patient why it is important. Minimize some of this teaching as their anxiety levels about the surgery may interfere with the retention of the information. Early ambulation impacts recovery positively with prevention of post op complications (DVT, Pneumonia, PE). Studies have shown a patient who remains in bed for 1 day will take a patient 3 days to regain strength, and are at more risk for post op complications. Pain management now often begins prior to surgery, with administration of medication before surgery to block pain pathways. However you do still encounter challenges with pain management due to surgeons misleading patients, telling them they won't have "any pain", or patient's social or medical history. Cognitive coping strategies- Reiki, essential oils, music to decrease anxiety. Some patients are axious about their body image as a result of their surgery, how it will impact their life ie. mastectomy, hysterectomy, leg amputation. Are they a caregiver? How am I going to care for X? How will I pay for this surgery and can I pay my bills since I can't work. These concerns may continue throughout their recovery process. Expected Outcomes: ⚫Relief of anxiety ⚫Decreased fear ⚫Understanding of the surgical intervention ⚫No evidence of preoperative complications

insulin

Interaction between anesthetics and insulin must be considered when a patient with diabetes is undergoing surgery. IV insulin may need to be given to keep the blood glucose within the normal range.

morphine sulfate

Long-term use of opioids for chronic pain (≥6 mo) in the preoperative period may alter the patient's response to analgesic agents.

Diazepam

May cause anxiety, tension, and seizures if withdrawn suddenly

chlorpromazine hydrochloride

May increase the hypotensive action of anesthetics.

Promoting Postop rest and comfort

Nausea and Vomiting Avoid giving large amounts of fluids or food at one time, especially after being NPO. Administer prescribed medications. Provide oral hygiene, as needed. Maintain clean environment. Avoid use of a straw. Avoid strong-smelling food. Assess for possible allergy to medications, such as antibiotics or analgesics. Maintain bowel elimination. Thirst Offer sips of water or ice chips when NPO (if permitted). Maintain oral hygiene. Hiccups Have the patient do the following: Take several swallows of water while holding the breath (if not NPO). Rebreathe into a paper bag. Eat a teaspoon of granulated sugar. Surgical Pain Assess pain frequently; administer prescribed analgesics every 2 to 4 hours on a regular schedule during the first 24 to 36 hours after surgery. Reinforce preoperative teaching for pain management. Offer nonpharmacologic measures to supplement medications: massage, position changes, relaxation, guided imagery, meditation, music.

Assessment of the surgical patient includes:

Obtaining a health history and performing a physical assessment to establish a baseline database Identifying risk factors and allergies that could cause surgical adverse events Identifying medications and treatments the patient is currently receiving Determining the teaching and psychosocial needs of the patient and family Determining postsurgical support and referral needs for recovery --> often conducted several days before the surgery

Unexpected Situations and Associated Interventions for Preop Care

Patient's laboratory results are noted to be abnormal: Notify health care provider. Some abnormalities, such as an elevated international normalized ratio (INR) or abnormalities in the complete blood count (CBC), may postpone the surgery. A patient says to you, "I'm not sure I really want this surgery": Ask the patient to elaborate on his or her concerns. Discuss with the patient why he or she feels this way. Notify the health care provider. Patients should not undergo surgery until any questions or doubts are resolved and they are sure that surgery is what they want.

minor surgery

Primarily elective -To restore function To remove skin lesions To correct deformities -Teeth extraction, removal of warts, skin biopsy

effective coughing

Place the patient in a semi-Fowler's position, leaning forward. Provide a pillow or folded bath blanket to use in splinting the incision. Ask the patient to: Inhale and exhale deeply and slowly through the nose three times. Take a deep breath and hold it for 3 seconds. "Hack" out for three short breaths. With mouth open, take a quick breath. Cough deeply once or twice. Take another deep breath. Repeat the exercise every 2 hours while awake.

deep-breathing technique

Place the patient in semi-Fowler's position, with the neck and shoulders supported. Ask the patient to place the hands over the rib cage, so that the patient can feel the chest rise as the lungs expand. Ask the patient to: Exhale gently and completely. Inhale through the nose gently and completely. Hold the breath for 3 to 5 seconds and mentally count "one, one thousand, two, one thousand," and so forth. Exhale as completely as possible through the mouth with lips pursed (as if whistling). Repeat three times. This exercise should be done every 1 to 2 hours while the patient is awake for the first 24 hours after surgery and as necessary thereafter, depending on risk factors and pulmonary status.

positioning after anesthesia

Positioning and length of surgery impacts the patient recovery, patient pain, location. Does the patient have a contracted extremity, or a previous or existing injury that requires special positioning? Were muscle relaxants used for general anesthesia? How long was the patient in this position? The OR staff pad bony prominences with gel pads to prevent skin breakdown. Imagine laying on an ironing board for 3 hours without moving. Being poked, tugged on, and having things shifted around internally.

Sample Preoperative Teaching: Activities and Events for In-Hospital Surgery

Preoperative Phase Exercises and physical activities Deep-breathing exercises Coughing Incentive spirometry Turning Leg exercises Early mobility Pain management Meaning of PRN orders for medications Multimodal pain medication options Timing for best effect of medications Splinting incision Nonpharmacologic pain management options Visit by anesthesiologist Physical preparation NPO Medications the night before/day of surgery Preoperative checklist (review items) Visitors and waiting room Transported to operating room by stretcher Intraoperative Phase Holding area Skin preparation Intravenous lines and fluids Medications Operating room Operating room bed Lights and common equipment (e.g., cardiac monitor, pulse oximeter, warming device) Safety belt SensationsStaff Postoperative Phase Postanesthesia care unit Frequent vital signs, assessments (e.g., orientation, movement of extremities, strength of grasp) Dressings/drains/tubes/catheters Intravenous lines Pain medications/comfort measures Family notification SensationsAirway/oxygen therapy/pulse oximetry Staff Transfer to unit (on stretcher) Frequent vital signs Sensations Pain medications/nonpharmacologic strategies NPO, diet progression Exercises Early ambulation Family visits

Examples of Nursing Activities in the Perioperative Phases of Care

Preoperative Phase Preadmission Testing 1.Performs initial preoperative assessment 2.Initiates education appropriate to patient's needs 3.Involves family in interview 4.Verifies completion of preoperative diagnostic testing according to patient's needs 5.Confirms understanding of surgeon-specific preoperative prescribed therapies (e.g., bowel preparation, preoperative shower) 6.Discusses and reviews advance directive document 7.Begins discharge planning by assessing patient's need for postoperative transportation and care Admission to Surgical Center 1.Completes preoperative assessment 2.Assesses for risks for postoperative complications 3.Reports unexpected findings or any deviations from normal 4.Verifies that operative consent has been signed 5.Coordinates patient education and plan of care with nursing staff and other health team members 6.Reinforces previous education 7.Explains phases in perioperative period and expectations 8.Answers patient's and family's questions In the Preoperative Area 1.Identifies patient 2.Assesses patient's physical and emotional status, baseline pain, and nutritional status 3.Reviews medical record 4.Verifies surgical site and that it has been marked per institutional policy 5.Establishes IV line 6.Administers medications if prescribed 7.Takes measures to ensure patient's comfort 8.Provides psychological support 9.Communicates patient and family's needs to other appropriate members of the health care team Intraoperative Phase Maintenance of Safety 1.Maintains aseptic, controlled environment 2.Effectively manages human resources, equipment, and supplies for individualized patient care 3.Transfers patient to operating room bed or table 4.Positions patient based on functional alignment and exposure of surgical site 5.Applies grounding device to patient 6.Ensures that the sponge, needle, and instrument counts are correct 7.Completes intraoperative documentation Physiologic Monitoring 1.Communicates amount of fluid instillation and blood loss 2.Distinguishes normal from abnormal cardiovascular data 3.Reports changes in patient's vital signs 4.Institutes measures to promote normothermia Psychological Support (Before Induction and When Patient is Conscious) 1.Provides emotional support to patient 2.Stands near or touches patient during procedures and induction 3.Continues to assess patient's emotional status 4.Notifies the patient's family or significant others of updates throughout the procedure Postoperative Phase Transfer of Patient to Postanesthesia Care Unit 1.Communicates intraoperative information: a.Identifies patient by name b.States type of surgery performed c.Identifies type and amounts of anesthetic and analgesic agents used d.Reports patient's vital signs and response to surgical procedure and anesthesia e.Describes intraoperative factors (e.g., insertion of drains or catheters, administration of blood, medications during surgery, or occurrence of unexpected events) f.Describes physical limitations g.Reports patient's preoperative level of consciousness h.Communicates necessary equipment needs i.Communicates presence of family or significant others Postoperative Assessment Recovery Area 1.Determines patient's immediate response to surgical intervention 2.Monitors patient's vital signs and physiologic status 3.Assesses patient's pain level and administers appropriate pain-relief measures 4.Maintains patient's safety (airway, circulation, prevention of injury) 5.Administers medications, fluid, and blood component therapy, if prescribed 6.Provides oral fluids if prescribed for ambulatory surgery patient 7.Assesses patient's readiness for transfer to inhospital unit or for discharge home based on institutional policy (e.g., Aldrete score, see Chapter 16) Surgical Nursing Unit 1.Continues close monitoring of patient's physical and psychological response to surgical intervention 2.Assesses patient's pain level and administers appropriate pain-relief measures 3.Provides education to patient during immediate recovery period 4.Assists patient in recovery and preparation for discharge home 5.Determines patient's psychological status 6.Assists with discharge planning Home or Clinic 1.Provides follow-up care during office or clinic visit or by telephone contact 2.Reinforces previous education and answers patient's and family's questions about surgery and follow-up care 3.Assesses patient's response to surgery and anesthesia and their effects on body image and function 4.Determines family's perception of surgery and its outcome

Nutrients important for wound healing

Protein Allows collagen deposition and wound healing to occur Collagen deposition leading to impaired/delayed wound healing Decreased skin and wound strength Increased wound infection rates Arginine (amino acid) Provides necessary substrate for collagen synthesis and nitric oxide (crucial for wound healing) at wound site Increases wound strength and collagen deposition Stimulates T-cell response Associated with various essential reactions of intermediary metabolism Impaired wound healing Carbohydrates and fats Primary source of energy in the body and consequently in the wound-healing process Meets demand for increased essential fatty acids needed for cellular function after an injury Spares protein Restores normal weight Signs and symptoms of protein deficiency due to the use of protein to meet energy requirements Extensive weight loss Water Replaces fluid lost through vomiting, hemorrhage, exudates, fever, drainage, diuresis Helps maintain homeostasis Signs, symptoms, and complications of dehydration, such as poor skin turgor, dry mucous membranes, oliguria, anuria, weight loss, increased pulse rate, decreased central venous pressure Vitamin C Important for capillary formation, tissue synthesis, and wound healing through collagen formation Needed for antibody formation Impaired/delayed wound healing related to impaired collagen formation and increased capillary fragility and permeability Increased risk for infection related to decreased antibodies Vitamin B complex Indirect role in wound healing through their influence on host resistance Decreased enzymes available for energy metabolism Vitamin A Increases inflammatory response in wounds, reduces anti-inflammatory effects of corticosteroids on wound healing Impaired/delayed wound healing related to decreased collagen synthesis; impaired immune function Increased risk for infection Vitamin K Important for normal blood clotting Impaired intestinal synthesis associated with the use of antibiotics Prolonged prothrombin time Hematomas contributing to impaired healing and predisposition to wound infections Magnesium Essential cofactor for many enzymes that are involved in the process of protein synthesis and wound repair Impaired/delayed wound healing (impaired collagen production) Copper Required cofactor in the development of connective tissue Impaired wound healing Zinc Involved in DNA synthesis, protein synthesis, cellular proliferation needed for wound healing Essential to immune function Impaired immune response

Some outcomes that frame plans of care for surgical patients might include that patients:

Receive respectful and culturally- and age-appropriate care Remain free from injury and adverse effects related to positioning, retained surgical items, or chemical, physical, or electrical hazards Experience no surgical site infection(s) Maintain fluid and electrolyte balance and skin integrity Maintain normal body temperature Collaborate in the management of their pain Demonstrate an understanding of the physiologic and psychological responses to their planned surgery Participate in their rehabilitation process following surgery

Some expected outcomes are that the patient will:

Remain free of neuromuscular injury Remain free from wrong-site, wrong-side, wrong-patient surgical procedure Maintain fluid and electrolyte balance Maintain skin integrity (other than for the incision) Have symmetric breathing patterns Be free of injury from burns, retained surgical items (inaccurate count of sharps, instruments, and soft goods such as surgical sponges used during the procedure), and medication errors Remain free from surgical site infection Maintain normothermia

STOP-BANG questionnaire

S = Snoring T= Tiredness O = Observed apnea P = Pressure (HTN) B = BMI (>35) A = Age (>50yo) N = Neck circumf (>40cm) G = Male gender

3 perioperative phases

The preoperative phase: Begins when the patient and surgeon mutually decide that surgery is necessary and will take place; ends when the patient is transferred to the operating room (OR) or procedural bed. ⚪Morning of surgery at home or in hospital ⚪Take to preop holding area ⚪Sign In to the OR The intraoperative phase: Begins when the patient is transferred to the OR bed; ends with transfer to the postanesthesia care unit (PACU). The PACU is an area often adjacent to the surgical suite designed to provide care for patients recovering from anesthesia or moderate sedation/analgesia. ⚪Time Out before starting ⚪Surgical Procedure done The postoperative phase: Begins with admission to the PACU or other recovery area; ends with complete recovery from surgery and the last follow-up health care provider visit. ⚪Sign out to PACU ⚪Discharge to home, to hospital floor or to ICU

palliative surgery

To relieve or reduce intensity of illness; is not curative Example: Colostomy, nerve root resection, debridement of necrotic tissue, balloon angioplasties, arthroscopy

ablative surgery

To remove a diseased body part Example: Appendectomy, subtotal thyroidectomy, partial gastrectomy, colon resection, amputation

preoperative information for outpatient/same-day surgery

Using simple language the patient can understand, instruct the patient (verbally and in writing) as follows: List medications routinely taken, and ask the health care provider which should be taken or omitted the morning of surgery. Notify the surgeon's office if a cold or infection develops before surgery. List all allergies, and be sure the OR staff is aware of them. Follow all instructions from your surgeon regarding bathing or showering with a special soap solution. Remove nail polish and, depending on the surgical site, do not wear makeup, lotions, or deodorant on the day of the procedure. Leave all jewelry and valuables at home. Wear clothing that buttons in front; short-sleeved garments are better for surgery on the hands. Have someone available for transportation home after recovery from anesthesia. Inform the patient of limitations on eating or drinking before surgery, with a specific time to begin the limitations. Notify the patient about when and where to arrive for the procedure, as well as the estimated time when the procedure will be performed.

patient-specific outcomes may include that the patient:

Verbalizes physical- and emotional-readiness for surgery Demonstrates coughing, turning, deep-breathing, and other postoperative exercises Verbalizes expectations of postoperative pain management Maintains fluid intake and nutritional balance to meet needs Q's on Preop Phase: ⚫Any questions on: ⚫Who does what ⚫Legalities ⚫Meds ⚫Your responsibility ⚫What if they don't want to go last minute ⚫Anything?

Postoperative Assessments and Interventions Upon Return to the Unit

Vital signs and oxygen saturation • Temperature, blood pressure, pulse and respiratory rates; oxygen saturation • Note, report, and document deviations from preoperative and PACU data as well as symptoms of complications Color and temperature of skin • Skin color (pallor, cyanosis), skin temperature, and diaphoresis Level of consciousness • Orientation to person, place, and time • Reaction to stimuli and ability to move all four extremities Intravenous fluids • Type and amount of solution, flow rate, security and patency of tubing • Infusion site Surgical site • Dressing and dependent areas for drainage (color, amount, consistency) • Drains and tubes; be sure they are intact, patent, and properly connected to drainage systems Other tubes • Assess indwelling urinary catheter, gastrointestinal suction, and other tubes for drainage, patency, and amount of output • Ensure that dependent drainage bags are hanging properly and suction drainage is attached and functioning • If oxygen is ordered, ensure placement of prescribed application and flow rate Comfort • Assess pain (location, duration, intensity) and determine whether analgesics were given in the PACU • Assess for nausea and vomiting • Cover the patient with a blanket • Reorient to the room as necessary • Allow family members to remain with the patient after the initial assessment is completed Position and safety • Place the patient in an ordered position, or • If the patient is not fully conscious, place in the side-lying position • Elevate the side rails and place the bed in low position

Unexpected Situations and Associated Interventions for Postop Care

Vital signs are progressively increasing or decreasing from baseline: Notify health care provider. A continued decrease in blood pressure or an increase in heart rate could indicate internal bleeding or hemorrhage. Dressing was clean before but now has large amount of fresh blood: Do not remove dressing. Reinforce dressing with more bandages. Removing the bandage could dislodge any clot that is forming and lead to further blood loss. Notify health care provider. Patient reports pain that is not relieved by ordered medication: After fully assessing pain (location, description, alleviating factors, and aggravating factors), notify health care provider. Pain can be a clue to other problems, such as hemorrhage. Patient is febrile within 12 hours of surgery: Assist patient with coughing and deep breathing. If ordered, encourage incentive spirometry. Continue to monitor vital signs and laboratory values such as complete blood count (CBC). Adult patient has a urine output of less than 30 mL/hr: Unless this is expected, notify health care provider. Urine output is a good indicator of tissue perfusion. Patient may need more fluid or may need medication to increase blood pressure if it is low.

Valid informed consent

Voluntary Consent Valid consent must be freely given, without coercion. Patient must be at least 18 years of age (unless an emancipated minor), a physician must obtain consent, and a professional staff member must witness patient's signature. Patient Who Is Incompetent Legal definition: individual who is not autonomous and cannot give or withhold consent (e.g., individuals who are cognitively impaired, mentally ill, or neurologically incapacitated). Informed Subject Informed consent should be in writing. It should contain the following: •Explanation of procedure and its risks •Description of benefits and alternatives •An offer to answer questions about procedure •Instructions that the patient may withdraw consent •A statement informing the patient if the protocol differs from customary procedure Patient Able to Comprehend If the patient is non-English speaking, it is necessary to provide consent (written and verbal) in a language that is understandable to the patient. A trained medical interpreter may be consulted. Alternative formats of communication (e.g., Braille, large print, sign interpreter) may be needed if the patient has a disability that affects vision or hearing. Questions must be answered to facilitate comprehension if material is confusing.

elective surgery

a procedure that is preplanned and based on the patient's choice and availability of scheduling for the patient, surgeon, and facility. This is a nonurgent procedure that does not have to be done immediately. Purpose: • To remove or repair a body part • To restore function • To improve health • To improve self-concept Examples: Tonsillectomy, hernia repair, cataract extraction and lens implantation, hemorrhoidectomy, hip prosthesis (may also be urgent), scar revision, facelift, mammoplasty

diagnostic surgery

done to make or confirm a diagnosis Example: Breast biopsy, laparoscopy, exploratory laparotomy

physical activities that reduce risk for surgical complications

deep breathing, coughing, incentive spirometry, leg exercises, turning in bed, and early ambulation

spinal anesthesia

injecting a local anesthetic into the subarachnoid space through a lumbar puncture, causing sensory, motor, and autonomic blockage. This type of anesthesia is used for surgery of the lower abdomen, perineum, and legs. Adverse effects of spinal anesthesia may include hypotension, headache, and urine retention.

In the preoperative phase, primary nursing interventions involve...

identifying risks and effectively teaching in an effort to minimize complications throughout the entire perioperative period. -ensure patient is mentally & physically prepared for surgery - preoperative teaching - physical preparation - psychological preparation - discharge planning

peripheral nerve blocks

injecting a local anesthetic around a nerve trunk supplying the area of surgery such as the jaw, face, and extremities. Onset and duration of the block depend on the anesthetic drug, its concentration, the amount injected, and the addition of additional medications (such as epinephrine) that prolong the block.

emergency surgery

must be done immediately to preserve life, a body part, or function Purpose: -To prevent further tissue damage -to preserve life • To remove or repair a body part • To restore function • To improve health • To improve self-concept Examples: Control of hemorrhage; repair of trauma, perforated ulcer, intestinal obstruction; tracheostomy

urgent surgery

must be done within a reasonably short time frame to preserve health, but is not an emergency Purpose: -to remove or repair a bofy part -to preserve life • To restore function • To improve health • To improve self-concept Examples: Removal of gallbladder, coronary artery bypass graft (CABG), surgical removal of a malignant tumor, colon resection, amputation

health history needed before a surgery

patient's developmental level medical history, including allergies medication history, including nonprescription drugs previous surgeries implants extremity limitations perceptions and knowledge of the surgery to be done nutrition use of alcohol, illicit drugs, or nicotine activities of daily living and occupation coping patterns and support systems sociocultural needs

Patients who smoke are more likely to experience

poor wound healing, a higher incidence of SSI, and complications that include VTE and pneumonia

immediate postop assessment and care

respiratory status (airway, pulse oximetry), cardiovascular status (blood pressure), temperature, central nervous system status (level of alertness, movement, shivering), fluid status (skin turgor, vital signs, urine output, wound drainage, and IV fluid intake including blood product administration), wound status (Large amounts of bright-red drainage, combined with other abnormal physical status assessments (restlessness, pallor, cool moist skin, decreasing blood pressure, increasing pulse and respiratory rates), may indicate hemorrhage and hypovolemic shock), gastrointestinal status (nausea and vomiting), and general condition. --> made every 10-15 min. (children every 5 min) --> Emergence delirium, waking up thrashing and disoriented, is common in children

reconstructive surgery

restore appearance or function due to trauma or illness --> improve self-concept Example: Scar revision, plastic surgery, skin graft, internal fixation of a fracture, breast reconstruction

Aspirin, clopidogrel, and other medications that inhibit platelet aggregation...

should be prudently discontinued 7 to 10 days before surgery

once entering the preop holding area, a nurse indentifies

surgical patient assess the patient's emotional and physical status verify the information on the preoperative checklist including assessment data lab reports -consents for surgery and blood transfusion

If a patient states that he or she is allergic to kiwi, avocado, or banana, or cannot blow up balloons...

there may be an association with an allergy to latex.

constructive surgery

to restore function in congenital anomalies Example: Cleft palate repair, closure of atrial-septal defect

risk factors for surgery that should be addressed prior

•Arthritis •Cardiovascular disease: •Coronary artery disease or previous myocardial infarction •Cardiac failure •Cerebrovascular disease •Arrhythmias •Hemorrhagic disorders •Hypertension •Prosthetic heart valve •Venous thromboembolism (VTE) •Dehydration or electrolyte imbalance •Endocrine dysfunction: •Adrenal disorders •Diabetes •Thyroid malfunction •Extremes of age (very young, very old) •Extremes of weight (underweight, obese) •Hepatic disease: •Cirrhosis •Hepatitis •Hypovolemia •Immunologic abnormalities •Infection and sepsis •Low socioeconomic status •Medications •Nicotine use •Nutritional deficits •Pregnancy: •Diminished maternal physiologic reserve •Preexisting cognitive, developmental, intellectual, physical, or sensory disability •Pulmonary disease: •Obstructive disease •Restrictive disorder •Respiratory infection •Renal or urinary tract disease: •Decreased kidney function •Urinary tract infection •Obstruction •Toxic conditions

same day admission

►Patient reports to pre-admissions testing (PAT) •Reconciliation of home meds •Evaluation by Anesthesia •Lab draws •Surgical consent obtained •COVID testing scheduled or performed depending on the date of surgery ►Phone call to patient the night before surgery with detailed instructions •Anti-bacterial scrub the night before and morning of procedure •all meds to be taken or held prior to arrival for surgery •Results of COVID test relayed to patient. If positive, procedure is cancelled or rescheduled. (all positive results are relayed to the patient by the surgeon) ►Patients report to designated area and are escorted to registration desk. •Family members may not escort patients to this point. (with few exceptions) •Patients are registered and seated consistent with hospital social distancing policy. ►Patients escorted to pre-op area to change into surgical attire and their personal affects secured. •Patient seen by interdisciplinary team members (i.e., anesthesia, OR nurses, Surgical Attending and residents, onsite pharmacist to confirm pre-op meds, infectious disease, endocrinology and nephrology, vascular, orthopedic, trauma (as needed)) •Registered nurse verifies all pertinent documents for process to continue

surgical asepsis

⚫All materials in contact with the surgical wound or used within the sterile field must be sterile ⚫Gowns -sterile in front from chest to level of sterile field, sleeves from 2 inches above elbow to cuff ⚫Sterile drapes are used to create a sterile field. Only top of draped tables are considered sterile ⚫Items dispensed by methods to preserve sterility ⚫Movements of surgical team are from sterile to sterile, from non-sterile to non-sterile only

preop factors that may potentially affect the surgical experience

⚫Medications and allergies ⚫Dentition ⚫Smoking/vaping, IVDA, ETOH, Marijuana or other substances ⚫Chronic pain ⚫Cardiovascular, renal, hepatic, & respiratory function ⚫Religious/cultural considerations ⚫Mental health/PTSD Review of information by the preop RN, Anesthesiologist, CRNA and OR nurse. Anesthesiologist/CRNA question patients about family members who have problems with anesthesia (malignant hyperthermia, pseudocholinesterase deficiency, genetic linked illnesses). These traits can impact the patient's safety, metabolism of anesthetics and care. A plan is developed based on the patient exam and history. Drug or food allergies can impact a patient's care. For example if a patient has an egg allergy they can't be given Propofol as it uses egg protein in the manufacturing. Drug allergies may result in a change in antibiotic administration. Iodine or shellfish allergy may require additional planning and treatment if a patient needs to have IV dye. Latex Allergies- certain fruit allergies are closely linked to latex allergies. Dentition- oral care should be done prior to sending a patient from the floors, note loose teeth, and implants. Smoking/vaping can affect the respiratory system, wound healing. In my experience as a nurse IVDA patients often maximize their drug usage. ETOH patients often minimize their ETOH usage. Marijuana impacts response to pain medication. Monitoring a patient for withdraw s/s from substances Chronic pain patients may need additional collaboration/consultation between anesthesiologist and a pain management Dr prior to surgery to manage their pain. Consultation with specialists to help direct patient care and management during the perioperative phases of care. To OPTIMIZE the patient. As surgery evolves so have the risks for bleeding. Surgeons use many techniques to minimize blood loss. Some hospitals call it blood less surgery, and employ the use of cellsaver devices collect the blood lost during surgery transfuse the patient's own blood back to them. Certain patients have traits that make them more at risk for bleeding, or clotting disorders Von Willenbrands, Hemophilia, Sickle Cell to name a few. Jehovah Witness do not allow for blood products to be administered. Hospital Chaplain for patients and families encountering surgery, each hospital may have their own policy regarding this. Cultural considerations may include a change in nursing assignment ie. a male RN may not take care of a female patient in certain cultures. PTSD preferred to know about it before surgery as it can impact the patient and staff safety. They will change the plan of care, medications and doses accordingly. Diuretics- these may be held for surgery or given due to a patient's symptomatology. Anticoagulants- treatment for AFib or other cardiac conditions, blood clotting disorders, Factor V Liden, require treatment either prior to or immediately after surgery with low molecular or unfractionated Heparin. Anesthesia is weight based, so a current and accurate weight is important. Obesity affects the positioning of the patient, the metabolism of the anesthetics used in OR. Propofol fat soluble an obese patient may take longer to metabolize the drug due to the drug's affinity to remain in the fat tissues. Insulin- BS control pre op and post op impacts wound healing. Diabetics usually have A1C, levels done preop. Special considerations for a patient with an insulin pump/sub Q BS monitor. Opioids - prevent withdraw/overdose Corticosteroids - patients may need dosing due to their underlying disease. Sometimes they are used to treat or prevent swelling of tissues or prevent/treat nausea. Herbal and OTC agents can impact patient care and are often discontinued prior to surgery. Some may increase bleeding risk Fishoil, ibuprofen. Body habitus can affect airway management. Anesthesia assesses patient airways for intubation, risk for OSA (obstructive sleep apnea). Patient's may need to bring their CPAP machine to the hospital. Disabilites may require additional assistance the day of surgery and post operatively. Bowel prep is required for certain surgeries. Skin prep preparation may include CHG Chlorhexidine gluconate antiseptic wipes to decrease bacterial load prior to surgery.

Preop surgical checklist

⚫NPO status, last time for solid or liquids ⚫Diabetic, blood sugar management ⚫Medications ⚫Antibiotics ⚫Functioning IV ⚫Type and Screen ⚫Blood products available ⚫Abnormal labs ⚫Removal of jewelry/body piercings, valuables, wigs, teeth glasses/contact lenses, hearing aides, clothing Completing the checklist is the responsibility of the RN. Last time for solid or liquids can vary depending on the age of the patient and the nature of the surgery. Medications cardiac medications, pre treatment for PONV and pain (Zofran SL, Emend, scopalamine patch, Acetaminophen, Gabapentin) Antibiotics SCIP (Surgical Care Improvement Project) Antibiotics are given w/in 1 hr, discontinued after 24 hrs. Type and Screen, is it still valid, after 72 hours a new one needs to be drawn. Blood products available and cross matched, presence of antibodies can delay surgery due to the need for blood. A patient's baseline starting the DOS (day of surgery) WBC, H&H, platelet count may impact the surgery. Abnormal labs need to be discussed with the surgeon, anesthesia, primary care and or consultants and corrected if possible prior to surgery, magnesium, potassium. Removal of jewelry, valuables Glasses/contact lenses, hearing aides, do the patients need these items to obtain consent. Remove clothing prior to surgery. Avoid the use of tampons in female patients.