Acute Exam 1

Hypothermia/fever prevention interventions post-op

passive warming (warmed cotton blanket, socks, limit skin exposure esp. with elderly) active warming (application of external warming devices like heated water mattress, heated humidified O2, warmed IV fluids) meticulous asepsis coughing/deep breathing dantrolene (dantrium) for malignant hyperthermia

sensory information

preop holding area may be noisy drugs and cleaning solutions may be odorous OR can be cold. Forced air warming devices may be used. Warm blankets are available. Talking may be heard in OR, but may be distorted because of masks. Ask questions if needed. OR bed will be narrow. Safety strap is applied over thighs Lights in OR may be bright and monitoring machines may be heard when awake

Sleep hygiene

reduce caffeine intake, avoid caffeine/alcohol/nicotine use at least 4-6 hrs before bedtime reduce light and noise don't go to bed unless sleepy, if you don't fall asleep within 20 min get back up find regular pattern for waking and sleeping begin rituals to help relax before bed (warm bath, light snack, reading) get full nights sleep on regular basis make bedroom quiet, dark, and a little bit cool do not read, write, eat, watch TV, talk on phone, or use technologies in bed do not go to bed hungry, but do not eat a big meal near bedtime either avoid strenuous exercise within 6 hrs of bed time avoid sleeping pills, or use them cautiously practice relaxation techniques to help cope with stress in your life

Pt teaching

sleep hygiene techniques how to use CPAP or BiPAP implement safety precautions when tired or if you have a sleep disorder like narcolepsy circadian rhythms

Relaxation strategies

state of physiologic and psychologic rest characterized by decreased SNS activity Relaxation Breathing: abdominal breathing done while sitting, standing or lying down ****The simplest and most effective way to stop the stress response is to breathe deeply and slowly Involves primary use of diaphragm and less use of upper chest and shoulders 4 by 4 breathing Meditation, Prayer, Imagery, Music, Massage, MINDFULNESS

procedural information

what to bring and what type of clothing to wear to surgery center any changes in time of surgery fluid and food restriction physical prep required (shower, bowel, or skin prep) purpose of frequent v/s assessment pain control and other comfort measures why TCDB post op are important, practice sessions preop insertion of IV lines procedure for anesthesia administration expect surgical site to be marked with indelible ink or marker

Sleep/pain/stress relationship

When you're in pain are stressed and you can't sleep then you're more stressed and pain is worse and it's just a big sad circle

Effects of cumulative sleep loss (Fig 7-3)

- lack of sleep effects all systems!!! Increases stress! Neurologic: cognitive impairment, behavioral changes (irritability, moodiness) Immune: impaired function Respiratory: asthma exacerbated during sleep Cardiovascular: heart disease (HTN, dysrhythmias), increased HR & BP in people with HTN, CVA (heart requires more oxygen) Gastrointestinal: increased r/f obesity, increased GERD; shut down and see more ileus, N/V Endocrine: increased r/f type 2 diabetes, increased insulin resistance, and decreased growth hormone

Infection prevention interventions

Assess the wound Note drainage color, amt, consistency Assess effect of position changes on wound/drain tube drainage S/S of infection Ordered prophylactic antibiotics Maintain glycemic control

Drug therapy non opioid analgesics with emphasis on nursing considerations

(1) Nonsalicylate → acetaminophen (tylenol) Chronic overdose: liver toxicity Rectal suppository and injectable form available, sustained preparations available, max daily dose 3 g Oral doses of >3g may cause hepatotoxicity Acute overdose: acute liver failure Max IV dose not more than 4g per day for adults over 50 kg - thrombocytopenia: coag studies - opioid sparing effect, lower pain scores, fewer side effects - activates own natural cannibinoids in system similar to MJ; hepatotoxicity reversal agent = acetylcysteine or activated charcoal (2) Salicylates → aspirin, choline magnesium trisalicylate Rectal suppository and sustained release preparations available Possibility of upper GI bleed Used more commonly in low doses as a cardioprotective measure than for its analgesic properties Unlike aspirin, choline does not increase bleeding time - risk for thrombocytopenia with aspirin -> reversal with sodium bicarb or activated charcoal (3) non opioid analgesics controls pain and does not alter consciousness, very effective in combo with opioid - treat pain based on cause, if inflammation treat with NSAID or non opioid, IV acetaminophen - analgesic ceiling: beyond upper limit and no effect; but also have no tolerance or dependence, OTC NSAIDs Ibuprofen Use lowest dose for shortest possible duration Increased risk for serious GI adverse effects, especially in older adults Increased risk for serious cardiovascular thrombotic events, MI, and stroke Increased risk for HTN and renal insufficiency - reduce prostaglandins, reduce serotonin in brain and soften pain center in brain - may still use very short term in cardiac patients regardless of risk Naproxen Use lowest dose possible Increased r/f GI bleeding Contraindicated for treatment of perioperative pain for CABG procedures Ketorolac (toradol) Limit tx to 5 days May precipitate renal failure in dehydrated patients (know hydration level: elevated BUN, elevated Hct, elevated electrolytes, MM, UO, turgor) Diclofenac K (cataflam) Use lowest dose for shortest time possible Available PO, ophthalmic, and topical Celecoxib (celebrex) Causes fewer GI SE than other NSAIDs, but is more expensive (can still have GI bleeding) May increase r/f cardiac thrombotic problems, MI, and stroke Risks may increase with duration of use, pre existing cardiovascular disease, or r/f for cardiac dz

Informed consent

(RN NEEDS AN ORDER TO OBTAIN CONSENT for surgery, blood, and anesthesia) ***3 required items (1) Adequate disclosure (RBAs) of diagnosis, nature and purpose of tx, risks and consequences of tx, probability of successful outcome, availability/benefits/risks of alternative tx, and prognosis if tx is not instituted (2) Pt has a clear understanding prior to sedative meds, even opioids; 3 hrs before (3) Voluntary consent - Surgeon has to explain all of these things to patient - contact surgeon about pt's need for additional info or if pt has questions, not nurses job to explain surgery - All the RN does is "witness the patient sign" and verify the pt has understanding, Ns is not responsible for education about procedure - Legally appointed representative of family may consent if pt is a minor, unconscious, or mentally incompetent Medical emergency may override need for consent - emancipated minor: under age but considered to have legal capacity for consent - if no power of attorney, possible consent = two surgeons are able to consent (must have consent for all possibilities) Have blood permit on hand Pt can back out at any time If language barrier, you need to get an interpreter If illiterate, ask pt questions about surgery to see if they understand - must be legal and ethical, ns is client advocate (#1), all required forms are to be on file/charted for pt, correct spelling and exact procedure (even multiple or optional procedures), must have surgical and blood permit/consent (even with invasive GI procedures such as colonoscopy => perforation could require blood) - voluntary: give them time to read it at good amount ahead of time and offer, instructions, and read it to them if they need it (no coercion) - Exception is if in emergent situations: 2 doctors can sign off, write out, and document incident report

Physiological assessment

***Determine baseline assessment pre op (ID chronic/acute issues & correct them before unless surgery is emergent, CMP, K+, Mg) - No steroids prior to surgery: they cause immunosuppression and increased blood sugar - determine status of age, nutrition, cardiac, renal, respiratory and immune to know risk - stop smoking 6wks prior, may need to delay if have upper infection - Stop all herbs/supp 2-3 wks prior to surgery and OTC (vitamins can be taken day before but can cause n/v) - Screen for latex allergy (risk factors: apple, avocado, melons, banana, carrot, celery, chestnut, raw potato, kiwi. contact urticaria/dermatitis, aerosol reactions, hx of reactions suggesting latex allergy) - blood transfusions if H&H is low, know that large blood volumes can decrease calcium b/c free Ca binds to citrate preservatives in the blood - SCDs are put on during surgery to prevent DVT - Allergies (drug and non drug, shellfish if contrast dye, and sulfur allergy in some anesthetics) Cardiovascular (major cause of death in pts) - Elderly at increased risk: decreased cardiac reserve (big fluid shift during surgery and heart can't take reserve -> heart attack), decreased ability to adapt and respond to stress (emergence delirium); mental status, increased anesthetic risk, compromised organ function, sensory deficits (age does not always determine risk) - also at increased risk for constipation from slowed GI and use of opioids - Is A fib normal for pt? Was it a part of baseline assessment? - ID any drugs (aspirin) or herbs (ginko) that may affect coagulation - meds to avoid: long term coag can be continued, stopped before and after, or withhold and use IV heparin - herbs & dietary supplements to avoid: garlic, vitamin E, ginkgo, fish oils (incr. bleed), ginseng & astraguls (incr. BP), kava & valerian (incr. sedation) ID acute/chronic problems (angina, HTN, recent MI, renal dz, diabetes) ID pt with heart valves, pacemakers, or defibrillators Assess for edema and JVD Baseline BP Cap refill, pulse rate/rhythm/quality (apical, radial, pedal)

Pay attention to the drug alerts

*respiratory depression and sedation higher in pts with acute pain treated with opioids* Morphine: may cause respiratory depression. If respirations are 12/min or less, withhold medication and contact HCP Methadone: may cause respiratory depression. NOT recommended in elderly. Can cause cardiac toxicity, specifically prolonged QT interval (get baseline for arrhythmia) NSAIDs: higher risk for cardiovascular events such as MI, stroke, and HF (except aspirin). Patients who have just had heart surgery should not take NSAIDs. Meperidine (demerol): not recommended as an analgesic - most critical: respiratory depression, may need O2 - watch for constipation (side effect of opioids): don't want them straining Fentanyl patches: may cause death from overdose. Signs of overdose include trouble breathing or shallow respirations, tiredness, extreme sleepiness, or sedation, inability to think, talk or walk normally, and faintness, dizziness, and confusion.

Importance of admin analgesic meds

- Age: elderly are very concerned with BM, at highest risk for constipation when using opioids - scheduling: around the clock with PRN for breakthrough pain is best - PREMEDICATE, titration, PCA, patches, being careful with opioid naive and knowing opioid users may need more medication (no threshold with opioids) - equinalgesic dosing: dose of one analgesic compared to another (converting) - PO, IV or CVL or PICC are best - PO route: use larger oral doses to equal same effect as IM and IV; do not crush sustained release tablets (1st pass effect) - SQ: not for acute pain; used at end of life, helpful for GI absorption problems and limited venous access - IM: not recommended: painful and result in poor absorption, abscesses and fibrosis - smaller doses for intraspinal: infection and catheter out of spinal space can cause problems (meningitis)

Table 8-10 opioid-induced sedation scale; know level of sedation and nursing intervention

- Assess: RR, rhythm (deep, rhythmic, slow, short, shallow), pulse ox, heart rhythm! Level of Sedation: S= sleep, easy to arouse. Acceptable, no action necessary, may increase opioid if necessary (OK) 1= awake and alert Acceptable, no action necessary, may increase opioid if necessary (OK) 2= slightly drowsy, easily aroused Acceptable, no action necessary, may increase opioid if necessary (OK) 3= frequently drowsy, arousable, drifts off to sleep during conversation Unacceptable. Monitor respiratory status and sedation level closely until sedation level is stable at less than 3 and respiratory status is satisfactory (NOT OK) Decrease opioid dose to 25% to 50% and notify HCP or anesthesiologist for orders. Consider administering a nonsedating, opioid-sparing nonopioid, such as acetaminophen or an NSAID, if not contraindicated - *must have protocol on chart with order specific for that, if no order must call Dr to get one, if Dr does not answer you can stop it until they get ahold of you, may bring in crash cart* 4= somnolent, *stop opioid*, minimal or no response to physical or verbal stimulation Unacceptable, (1) stop opioid. (2) Consider administering naloxone, (3) notify HCP or anesthesiologist. (4) Monitor respiratory status and sedation level closely until sedation level is stable at less than 3 and respiratory status is satisfactory - need order or agency policy crash cart, need NARCAN!!!

Sensitization & referred pain

- Central sensitization is caused by increased sensitivity and hyperexcitability of neurons in the CNS - Peripheral sensitization is caused by tissue damage and prolonged exposure to noxious particles in inflammatory process - Referred pain must be considered when interpreting the location of pain reported by the person with an injury or disease involving visceral organs, the location of a stimulus may be distant from the pain location reported by the patient (pain in some area that originated somewhere else) - head, neck, jaw pain = anginal pain - abd pain = complain of pain in back - transfer of pain due to phrenic nerve

Discharge criteria for PACU & discharge teaching

- Discharge teaching: joint commission requirements (summary: reason, significant findings, care/H&P, discharge info to family if going to other facility; meds/diet/activity level followup and discharge info for pain management if going home; H&P in chart, pain re-assess q hour including SE) - legal and ethical issues (consent, right to refuse), safety and home Criteria: - include SBAR handoff report Teaching: - symptoms to be reported, drugs, care of incision and dressings, activities allowed, dietary restrictions, follow-up, answering any questions

Table 17-7 Preoperative fasting recommendations

- NPO rationale is to reduce the risk of pulmonary aspiration and postoperative N/V - (diabetic patients with gastric paresis may need alternative foods- lighter meal at midnight before NPO) Clear liquids (water, clear tea, black coffee, chicken broth, carbonated beverages, fruit juice without pulp) → 2 hr minimum fasting period Breast milk → 4 hr minimum fasting period Nonhuman milk, including infant formula → 6 hr minimum fasting period Light meal (toast and clear liquids) → 6 hr minimum fasting period Regular meal (may include fried or fatty food, meat) → 8 hr minimum fasting period

Gero considerations for surgery

- aging affects absorption, distribution, and metabolism of meds - altered onset, peak and duration so anesthesia needs to be titrated - altered response to anesthesia and blood and fluid loss and replacement, hypothermia, pain, tolerance of surgery and positioning - altered hearing and vision so make communication clear and concise (sensory impairments, education) - skin at risk for injury with dressings and certain prep solutions - positioning due to osteoarthritis/porosis - greater risk for postop hypothermia (consider use of warming devices) Postop: - decreased respiratory function, decreased ability to cough and thoracic compliance - increase work of breathing and ability to eliminate drugs - pneumonia is common postop complication - vascular function altered due to atherosclerosis and decreased elasticity in blood vessels - cardiac function compromised, limited ability to undergo changes in BP and volume - decreased blood volume may cause hypertension is common - drug toxicity: renal perfusion is decreased and ability to remove drugs, decreased live function and ability to metabolize drugs - changes in mental status due to possible delirium postop - pain control is difficult

Principles of aseptic technique in the operating room T 18-3

- all materials that enter the sterile field must be sterile. if a sterile item comes in contact with an unsterile item, it is contaminated. contaminated items are removed immediately from the sterile field. If the sterile item is small, once it is removed, the area is marked off/covered with a sterile drape. If the entire field is contaminated, it should be set up again with all new materials. - the surgical team working in the operative field must wear sterile gowns and gloves. Once dressed for the procedure, they must recognize that the only parts of the gown considered sterile are the front from the chest to the table level and sleeves to 2 inches above elbow. a wide margin of safety must be maintained between sterile and unsterile fields. - tables are considered sterile only at tabletop level. Items extending beneath this level are considered contaminated. the edges of a sterile package are considered contaminated once the package has been opened. If a sterile package is placed on the sterile field, that entire package remains sterile even when opened. microorganisms travel on airborne particles and will enter the sterile field with excessive air movements and currents. microorganisms travel by capillary action through moist fabrics., resulting in contamination. microorganisms harbor on the patient's and team members' hair, skin, and respiratory tracts and must be confined by appropriate attire.

Fluid & Electrolyte Nutritional status assessments

- assess serum electrolyte levels prior to surgery, use of diuretics, pts at risk for dehydration, preop fluid balance history - nutriton: obesity and thin (may need more padding on table) - deficiencies alter recovery (if severe enough surgery may be postponed) - Protein and vitamins A, C, and B complex deficiencies are particularly significant because these substances are essential for wound healing - supplemental nutrition for malnourished can be given preop - elderly are at risk for malnutrition and fluid volume deficit - assess caffeine consumption, may need to be held before surgery (cause headache confused with a spinal headache), relieved by giving caffeine postop - economic status, smoking, alcohol consumption - ***protein (may need to supplement), Vit A, C, E for skin and healing, B complex vitamins for RBC, iron (blood transfusion need)

Sedation and respiratory depression in opioid/other drug use

- if the number of patient's respirations falls below 8-10 bpm and the sedation level is 3 or greater, you should (1) vigorously stimulate the patient and try to keep the patient awake - if the pt becomes over-sedated, (3) administer oxygen - in this situation, the (2) opioid dose should be reduced - (4) Naloxone SQ, intranasal, or IV - if pt taking opioids regularly: use naloxone carefully b/c it can precipitate severe, agonizing pain, takes all of the opioid blockers off the receptors; profound withdrawal symptoms; hypertension; and pulmonary edema; because its half life is shorter than most opioids: monitor frequently because pt can go back into respiratory depression (IV q 2 min) - increased sedation = increased r/f aspiration Risk factors for SE of opioids: > 65, history of snore/apnea, underlying cardiorespiratory, obesity, on benzodiazepine/CNS depressant place these pt at greatest risk - educate family about reasons for disturbing pt and need for assessing for respiratory depression - pruritus (itching): low dose infuse of naloxone - opioid induced hyperalgesia (OIH): state of nociceptive sensitization caused by exposure to opioids - corticosteroids can be used to decrease inflammation and edema: do not use with NSAIDs - anti-seizure drugs: carbamazepine & phenytoin used for neuropathic pain & fibromyalgia (also gabapentin) - Baclofen: neuropathic pain and muscle spasms (GABA agonist) - Clonidine: alpha 1 agonists (intrathecal use for neuropathic pain) - antidepressants: TCAs prevent reuptake of SE and NE for neuropathic pain - cannabis: SE projectile vomit - (1) basal, (2) bolus, (3) pt controlled PCA pumps

Basic principles of pain assessment

- onset, location, duration, character (pattern, quality, intensity), aggravating, relieving, radiating, timing of it, (OLDCARTS) how does pt talk about pain, what words do they use?, what does their definition of "uncomfortable" or "in pain" mean? Is this a different pain then you have had before? Neuropathic or acute incisional tissue injury nociceptive pain? (document words being used) - pain pattern: around the clock - quality: adjectives like burning, throbbing - Intensity: use scale - location: where patients have the right to appropriate assessment and management of pain assess pain in all patients pain is always subjective pt's self report of pain is the single most reliable indicator of pain. accept and respect this self report unless there are clear reasons for doubt physiologic and behavioral signs of pain are not reliable or specific for pain do not rely primarily on observations and objective signs of pain unless the patient is unable to report pain pain is an unpleasant sensory and emotional experience address physical and psychological aspects of pain when assessing pain pain can exist when no physical cause can be found do not attribute pain that does not have an identifiable cause to psychological causes different patients experience different levels of pain in response to comparable stimuli a uniform pain threshold does not exist patients with chronic pain may be more sensitive to pain and other stimuli pain tolerance varies among and within individuals depending on various factors, such as genetics, energy level, coping skills, and prior experience with pain. unrelieved pain has adverse consequences. - Acute pain that is not adequately controlled can result in physiologic changes that increase the likelihood of developing persistent pain (can result in chronic pain) - encourage patients to report pain, especially patients who are reluctant to discuss pain, deny pain when it is probably present, or fail to follow through on prescribed treatments - pain thermometer: pain as bad as could be, extreme, severe, moderate, mild, no pain (0-5)

Other prep preop

- psychological/social: full disclosure (HIPAA, privacy and security), surgeon and anesthesiologist (both will come to the floor or preop and do assessment, meds, and hx and talk to pt); address concerns, anxiety and fears, knowledge deficit - always use open ended questions and let pt voice fears and express needs (no yes/no questions at all!!!) - knowledge deficit is HUGE: "fear of the unknown", educate can improve outcomes, everything is said in confidence - education: manage anxiety! - content: (1) preop: instruct in what happens going in, IV, foley, and talk about TCDB/early ambulation and other postop stuff because good time now than later, and leg exercises and equipment, pain control, machines, noises, and monitors, tubes/lines, and what to expect in post op setting (let family know too) (2) intraop: roles, flow, new rules for preventing hypothermia (OR is warmer and incr. circulation) (3) postop: SCD, walking, incentive spirometer, meds; insulins use: even in non DM pt due to medical induced hyperglycemia and need to control glucose levels to increase healing (4) principles: incentive, small parts, specific, NOT right before going home, learner type - sensory procedural and process information (DO AT ALL TIMES, can decrease complications, length of hospital, and recovery time) - physical and spiritual - communication, stress, anxiety and pain: communication- plan (PCA and bowel prep), advocate (orders not affective for pt), and interpret; stress anxiety and pain addressing (increased cortisol levels can be good, but if prolonged can cause decr. immune, decr. bone density, incr. glucose, don't judge their response, help them cope!) - clients with special needs: gero considerations, sensory impairment, education, physical impairment (bed to chair) - safety: allergies, skin prep/surgical marking, preop check list, positioning and draping, time out prior to procedure, hazards

Opioids

- pure opioid agonists: bind to opioid receptors, no analgesic ceiling, up and up causes respiratory to decrease - SE: pupil constriction, dry mouth, urinary retention, increase body temperature, mute sympathetic nervous system (decr. HR, RR, etc.) - main problem is respiratory depression - most common is constipation can lead to GI obstruction (can lead to visceral pain), may induce vomiting and have abd distention - may have N/V so treated with Zofran which causes more constipation, monitor bowel function/output, gas release - itching/pruritus: PCA and epidural, get one of the -cain to help with itching, oral benadryl Morphine: can cause histamine release (itching), give reglan with it if n/v - itching = give Benadryl Dilaudid (hydromorphone): slightly shorter duration than morphine (know mg, not volume), very powerful, 8x more powerful than morphine Methadone: accumulates with repeated dosing, use with caution in older adults (know mcg) - transdermal route: for chronic pain and not for opioid naive patients Fentanyl: very potent! Dosed in mcg, immediate onset if IV. transdermal only for chronic pain, should not be used in opioid-naive patients; mcg are very strong, use patch, not something you want to keep on for very long time Oxycodone: PO (short acting and extended-release forms); single or combo, mod-severe pain, extended-release for chronic pain Tramadol: PO (short acting and extended release), dual mechanism of action: mu opioid agonist and blocks reuptake of NE and serotonin; used for moderate pain Demerol: associated with neurotoxicity and seizures, not as used anymore Codeine oral (tylenol #3): higher incidence of nausea and constipation than other mu agonists - PO short acting and extended release forms Mixed agonists-antagonist - Talwin & Butorphanol: less respiratory depression, not as concerning; but is still a risk for respiratory depression; act on mu receptor

Heat and Cold therapies

- visceral pain = no heat, decrease peristalsis and acid production, contraindicated if deep visceral inflammatory process/infection, can cause rupture - cold therapy increases peristalsis, preferred over heat for abd pain (ileum, bowel obstruction), more effective than heat therapy

Nurses role in sleep management

-schedule medications and procedures, bundle care and not interrupt every 30 min, intervene and advocate for pt -reduce light and noise levels -hypnotic medications PRN - help them maintain sleep ritual: read, TV, bathing - manage pain!!! - sleep apnea considerations: CPAP (continuous pressure makes it easier to breathe in and hard to breathe out, needed to keep airway open) and BiPAP (decrease pressure during exhalation phase); bring own from home, send it down with them to surgery, will use after surgery - education on the importance of getting sleep and resting especially if immunocompromised

Diagnostics

ABGs, pulse ox → respiratory and metabolic function, oxygenation status (95%+) Blood glucose → metabolic status, diabetes (60-100) BUN, Cr → renal function (BUN: 7-20, Cr: 0.5-1) Chest xray → pulmonary disorders, cardiac enlargement, heart failure CBC (RBC, Hgb, Hct, WBC) → anemia, immune status, infx (Hgb: 12-15; Hct: 35-45 & 40-50%; RBC: 4-5, WBC: 5-10, Plt: 150-450, BP: 120/80) Electrocardiogram → cardiac disease, dysrhythmias Electrolytes → metabolic status, renal function, diuretic side effects (Na: 35-45, K: 3.5-4.5, Ca 8.5-10.5) hCG → pregnancy status LFTs → liver status (ALT & AST <30-40) PT, PTT, INR, PLT count → coagulation status (PT: 11-13.5, INR: 0.8-1.1, PTT: 25-35) PF studies → pulmonary status Serum albumin → nutritional status (3.5-5.4) T&C → blood available for replacement (elective surgery pts may have own blood available) UA → renal status, hydration, UTI

Acute vs. Chronic pain

Acute: Comes on suddenly, short-lived (trauma, surgery, onset of injury), usually a warning sign Results from disease, inflammation or injury to tissues Accompanied by anxiety and emotional distress Self-limiting Physiologic responses (HR, RR, BP all rise) If untreated, acute pain can become chronic Chronic: Exists over longer period of time (>3-6 mos.) Pain persists despite the fact the injury has healed Resistant to most medical therapies Made worse by environmental/psychologic factors Physical and Psychologic effects (sleep disorders, anxiety, depression) Loss of autonomic signs Usually accompanied by anxiety or stress/sleeplessness, suffering, depression and pt on meds for those (can be associated with or without tissue injury, unpredictable, resistant to usual meds)

Potential problems in the postoperative period: respiratory complications

Airway obstruction (commonly caused by patients tongue) Hypoxemia Atelectasis (alveolar collapse caused by bronchial obstruction caused by retained secretions, decreased respiratory excursion, or general anesthesia; diminished or absent breath sounds) - the most common cause of postop hypoxemia; other causes include pulmonary edema, PE, aspiration, bronchospasm Pulmonary edema (fluid overload, hear crackles, increased cap permeability, etc.) Aspiration (inhalation of gastric contents to lungs) Bronchospasm (increased smooth muscle tone with a small airway) - upper airway obstruction from secretions: deeper sound over large bronchi, deep breath and cough can clear those rhonchi (cleared with cough) - crackles heard in lower areas, not cleared with cough - wheezing/stridor if constriction Hypoventilation (CNS depression, poor muscle tone, pain, mechanical restriction, monitor when giving opioids, use sedation scale)

Table 19-3 PACU assessment

Airway: patency, oral or nasal airway, laryngeal mask airway, endotracheal tube with ventilator settings Breathing: RR and quality, auscultated breath sounds, pulse oximetry, capnography or other technology supported monitoring if indicated, supplemental O2 Circulation: ECG monitoring- HR and rhythm, BP- noninvasive or arterial line, hemodynamic pressure readings (if applicable), temperature, cap refill, color/temperature/moisture of skin, apical and peripheral pulses Genitourinary: urine output Neurologic: LOC, orientation, sensory and motor status, pupil size and reaction Gastrointestinal: nausea, vomiting, intake (fluids, irrigations), output (vomitus), bowel sounds Surgical site: dressings and visible incisions, drains (type, patency, and drainage), IV assessment (location and condition of sites, solutions infusing)

Catastrophic events that can happen during surgery

Anaphylaxis Could be masked by the anesthesia Malignant Hyperthermia Could look like fever, muscle spasms, incr. HR If someone in your family has experienced this, everyone needs to have their chart flagged Tx: dantrolene (dantrium)

Gastrointestinal assessment

Anesthesia and pain meds slow GI Nutrition Provide extra padding to underweight pt to prevent pressure ulcer May be protein and vitamin deficient Obesity increases r/f T2DM (post op healing prolonged r/t decreased blood flow and increased adipose tissue) Patterns of food and fluid intake, recent weight changes Meds: watch for metformin (increases risk for lactic acidosis, 48 hours before and after, and blood thinners) Usual bowel pattern and date of LBM and auscultate bowel sounds Use of dentures and bridges (loose dentures or dislodging of teeth with intubation) Weigh the pt !!!focused assessment!!!

Commonly used preoperative medications Table 17-8

Antibiotics → Cefazolin (ancef) Prevent post op infx Anticholinergics → atropine, glycopyrrolate (robinul), scopolamine (transderm-scop) Decreased oral and respiratory secretions Prevent n/v Provide sedation Antidiabetics → insulin (humulin R) Stabilize blood glucose Antiemetics → Metoclopramide (Reglan), ondansetron (zofran) Increased gastric emptying Prevents n/v Benzodiazepines → midazolam, diazepam (valium), lorazepam (ativan) Decrease anxiety, induce sedation, amnesic effects *reversal agent: flumazenil* Beta blockers → labetalol Manage hypertension Histamine h2 receptor antagonists → famotidine (pepcid), ranitidine (zantac) Decrease HCl acid secretion, increase pH, decrease gastric volume Opioids → morphine (duramorph), fentanyl (sublimaze) Relieve pain during preoperative procedures *reversal agent: narcan* **need quiet, calm, dark post op environment b/c ketamine cx hallucinations and nightmares**

Potential problems in the postoperative period: GI complications

BEST INDICATOR OF BOWEL HEALTH IS BM OR PASSING GAS Post op n/v (PONV) -most common complication R/F: younger age (<50), female, hx of motion sickness, hx of PONV Constipation Ileus (temporary impairment of gastric and bowel motility after surgery resulting from the handling or reconstruction of intestine during surgery and limited dietary intake before/after surgery.... After abd surgery, motility in LI may be reduced for 3-5 days even tho SI resumes within several hours) R/F: opioids, immobility, older age, previous abd surgery, early postop feeding S/S: abd cramps, increasing abd distention, complains of v/c, dehydration Delayed gastric emptying - High pitched sound = obstruction from build up of air or distention in abd Hiccups (caused by irritation of phrenic nerve)

General anesthesia table 18-6 with emphasis on the nursing interventions and considerations

Barbiturates → methohexital (brevital) Usually have minimal postoperative effects because of short duration Increased incidence of postoperative nausea in patients with barbiturate sensitivity, histamine triggered nausea, and vomiting. - Nonbarbiturate hypnotics Etomidate (amidate) Observe for transient skeletal muscle movement, n/v, hiccups, hypotension, and hypoglycemia Propofol (diprivan) Monitor for postoperative hypotension and bradycardia Monitor serum triglycerides q24hr when sedated for >24 hr - Volatile liquids → isoflurane (forane), desflurane (suprane), and sevoflurane (ultane) Assess and treat pain during early anesthesia recovery. Assess for adverse reactions such as cardiopulmonary depression with hypotension and prolonged respiratory depression Monitor n/v - Gaseous agents → nitrous oxide Avoid in patients with bone marrow depression - Dissociative anesthetic → ketamine (ketalar) Anticipate administration of a benzodiazepine if agitation and hallucinations occur. Calm, quiet environment is essential in postoperative care.

Table 19-4 Signs of inadequate oxygenation

CNS: restlessness, agitation, confusion, muscle twitching, seizures, coma Respiratory System: increased to absent respiratory effort, use of accessory muscles, abnormal breath sounds, abnormal ABGs CV: hypertension, hypotension, tachycardia, bradycardia, dysrhythmias, delayed cap refill, weak peripheral pulses, decreased O2 saturation Integumentary: flushed/cool/moist skin, cyanosis Renal System: Urine output <0.5 mL/kg/hr

Neuropathic pain

Caused by damage to peripheral nerves or structures in CNS (numbing, hot, burning, shooting, stabbing, sharp, electric shock like; sudden, intense, short lived and lingering) - NO RESPONSE TO OPIOIDS ALONE (not well controlled) - do multimodal, adjunct treatment Abnormal processing of sensory input by the PNS or CNS Treated by adjuvant therapies - pain outside the norm ex. rubbing sheet across foot, diabetic neuropathy cx pain Types: 1. Central pain: caused by primary lesion or dysfunction in CNS. ex. Poststroke pain, pain associated with MS 2. Differentiation pain: due to amputation or mastectomy 3. *Peripheral neuropathies*: pain felt along the distribution of one or many peripheral nerves caused by damage to the nerve. Ex. peripheral neuropathy, alcohol-nutritional neuropathy, trigeminal neuralgia, postherpetic neuralgia, shingles 4. CRPS: neuro-p, more susceptible to pain, more sensitive to small things

Surgery puts any pt at risk for what? how should Weight be considered?

DVT: virchow's triad of endothelial injury (from surgery), hyper-coagulation from body's reaction (stress) to surgery, and venous stasis from bedrest after surgery - also at risk for PE - consider weight with all pt's: puts pressure on chest and affects surgical position and makes access to the surgical site more difficult and weight affects anesthesia; it predisposes the pt to wound dehiscence, wound infection and incisional herniation postop --Adipose tissue is less vascular than other types of tissue, in addition the pt may be slower to recover from anesthesia because inhalation agents are absorbed and stored by adipose tissue thus leaving the body more slowly (can circle back around and release effects later; pts may be instructed to decrease wt before surgery)

Potential problems in the postoperative period: neurologic complications

Emergence delirium (short term neuro alteration seen as restlessness/disorientation/agitation/shouting, caused by hypoxemia/postop pain/long duration of preop fasting) Delayed emergence (most common cause is prolonged drug action of opioids/sedatives/residual neuromuscular blockade/inhalation anesthetics) Anxiety Postoperative cognitive dysfunction (POCD) (decline in pt cognitive function for weeks or months postop, primarily seen in older patient) Alcohol withdrawal delirium (restlessness, insomnia, nightmares, irritability, hallucinations)

Intra-op order of actions

FLOW While in the holding area, make sure the patient has an ID armband, allergy band, and no nylon on When you get the call to take the pt to the operating room, have the pt go to the bathroom. Have them get back in bed, THEN give them pain meds and other things that are ordered Atropine is the typical anticholinergic given to dry the pt out - Different general, local, regional anesthesia - alertness with brain surgery and anesthesia - need quiet, calm, dark post op environment b/c ketamine cx hallucinations and nightmares - benzos: respiratory depression, flumazenil antidote - antiemetics - opioid reversal agent = narcan 18-1, 18-2, 18-6, 18-7

Coping mechanisms

Find out what helps the pt and provide that for them Positive strategies: may include exercise or spending time with friends and family Negative strategies: may include substance abuse or denial, eventually leading to increased stress Emotion focused coping: managing emotions that one feels when a stressful event occurs Helps decrease negative emotions and help create a feeling of well being - useful when a situation is unchangeable or uncontrollable Problem focused coping: finding solutions to resolve problems causing stress Allows one to look at a challenge objectively, take action/address the problem & reduce the stress - useful if a problem can be changed or controlled Coping by breathing deeply and slowly to increase oxygenation - 4x4 technique: 1,2,3,4 count breathing, holding, and exhaling - imagery, music, back rub, relaxing sigh, TENS

Potential problems in the postoperative period: fluid & electrolyte complications

Fluid overload Fluid deficit Electrolyte imbalances Hypokalemia Acid-base imbalances - could have hypocalcemia if transfused large volume of blood, cue to binding to citrates preservatives

Cardiac prevention interventions

Frequent v/s monitoring (TRENDS!!!) continuous ECG monitoring adequate fluid replacement assess surgical site for bleeding intake and output monitor laboratory results Potassium 3.5-5.0 BUN/Creatinine 7-20, 0.6-1.2 Magnesium 1.5-2.5 Hgb/Hct 12-17, Hct 37-52 early ambulation VTE prophylaxis monitor for orthostatic BP with increase in mobility slow changes in body position

Hepatic assessment

Hx of substance abuse (esp ***alcohol*** and IV drug use) Skin color and sclera for jaundice - check function of liver to determine ***medication clearance*** especially for detox of anesthesia (RISK FACTOR) - albumin: if low could cause poor healing, 3rd spacing and swelling and is bad for kidneys) - check prothrombin and other clotting factors (produced by liver)

Potential problems in the postoperative period: cardiovascular complications

Hypotension Hypertension Dysrhythmias (hypoxemia, hypercapnia, electrolyte and acid base balance) VTE (venous thromboembolism) Syncope (fainting → indicates decreased CO, fluid deficits, and defects of cerebral perfusion) - decreased circulation and think about pressure/breakdown to extremities - know pedal pulses

Pain Fibers, chemical agents, and gate theory

In acute pain situation: see acute stressors - if having acute pain, massage them you block out acute pain (gate theory) - turn and reposition pt can cause a blocking of some of the fibers or touch - certain places where pain can be modified, every synapse and brain process - histamine involved in inflammation that can induce pain (peripheral) - bradykinin powerful vasodilator, incr. capillary permeability, constricts smooth muscle, role in chemistry of pain at site of injury (peripheral) - serotonin pain inhibitor (modulator) - prostaglandins hormone like substance that sends additional pain stimuli to CNS (peripheral) - substance P stimulant at pain receptor sites and influence inflammatory process (central) - location of pain makes a big difference: different nerves Alpha: largest nerve fiber with a lot of myelination: spacial awareness and positioning, very fast fiber A-beta: medium, touch, less myelination, slower A Delta: smaller, feel pain, sharp pain, fast, more myelin C fiber: smallest, dull pain, much slower

Neurologic assessment

KNOW BASELINE! r/f CVA is great (pre op vs. post op) Oriented x 3? Note presence of confusion, disordered thinking, inability to follow commands Hx of CVA, TIA, or neurologic dz (Parkinsons, MS) - get coagulation studies to determine risk for stroke postop

Legal/ethical issues

Make sure all required forms are signed and in chart (informed consent, blood transfusions, AD, power of attorney: who needs to be contacted) - Joint Commission requires H&P to be in patient's chart - Preop teaching MUST be documented and reported to post op nurses - Do preop checklist before patient is given any sedating drugs - Ex. consents, advance directives, durable power of attorney, emergency situation, mentally incompetent, illustrate, language barrier - Living wills: no legal weight, even though on chart, can't use it as legal order, doctor must write order (for DNR), you can take info and concerns to doctor to get order and be advocate - get clarity on any legal document - mentally incompetent: must have someone for them and with minors - illiterate: can read aloud to them but must be documented, if can't sign name, have them make a mark of approval and go in after them and sign that that was their signature - language barrier: no family member, need translator

Nociceptive pain

Normal processing of stimulus that damages normal tissue or has the potential to do so if prolonged Treated by non opioid/opioid drugs - stimulation of peripheral nerve fibers, cutaneous (skin), visceral (organs: respond to stretch, inflammation, ischemia), somatic (joint, pain, muscle) ex. stoma does not have same nerve fibers, touch stoma and usually won't hurt, can cause feelings of ischemia pain, stretch pain from bowel obstruction or gas build up in GI Types: 1. Superficial somatic pain: arising from skin, mucous membranes, SQ. localized. Ex. sunburn, skin contusions (sharp, burning, prickly) 2. Deep somatic pain: arising from muscles, fasciae, bones, and tendons. Localized, diffuse, and radiating. Ex. arthritis, tendonitis, myofascial pain (aching/throbbing) 3. Visceral pain: from visceral organs, such as GI tract and bladder. Well or poorly localized, often referred to cutaneous sites. Ex. appendicitis, pancreatitis, IBS, bladder syndromes (respond to inflammation, stretching and ischemia, cramping pain caused by stretch receptors, no nerve endings)

Respiratory assessment

Obesity and weight (laying supine suppresses diaphragm, also affects anesthesia: see above) - Stop smoking 6 wks prior to surgery (Resp and Cardiac) ID acute/chronic problems (infection, COPD, asthma, use of CPAP); must delay surgery if have current lung infection Tobacco hx? Baseline O2 and RR and rhythm Observe for cough, dyspnea, use of accessory muscles Auscultate lungs for normal and adventitious breath sounds - Ask about medications: COPD pts take corticosteriods (can't stop abruptly) that increase glucose, decrease immune system, and decrease wound healing causing slower recovery and increased infection risk; also consider beta blockers affect on heart/lungs (slow heart rate and bronchoconstriction)

Musculoskeletal assessment

ROM before vs. after Skin around pressure points Joint or muscle pain Assess mobility, gait, balance - physical activity before to compare to after - checking calcium and potassium levels - signs of low calcium = chvostek's and trousseau's sign (also tingling of the fingertips)

Adjunct to general anesthesia table 18-7 with emphasis on the nursing interventions and considerations

Opioids → fentanyl (sublimaze), sefentanil (sufenta), morphine sulfate, hydromorphone (dilaudid), alfentanil (alfenta), remifentanil (ultiva), methadone (dolophine) Assess respiratory rate and rhythm, monitor pulse oximetry, protect airway in anticipation of vomiting. Use standing orders for antipruritics and antiemetics Reverse opioid induced respiratory depression with naloxone (narcan). If used, reversal of analgesic effects also occurs. Reglan is often given with morphine for prevention of nausea and vomiting Benzodiazepines → midazolam (versed), diazepam (valium), lorazepam (ativan) Monitor level of consciousness. Assess for respiratory depression, hypotension, and tachycardia Reverse severe benzodiazepine-induced respiratory depression with flumazenil (romazicon) Neuromuscular blocking agents → Succinylcholine (anectine), pancuronium, -onium drugs If intubated, monitor return of muscle strength, LOC, and ventilation (*SE: hypoventilation*) Maintain patent airway, monitor RR and rhythm until patient able to cough and return to previous level of muscle strength. Ensure availability of nondepolarizing reversal agents and emergency respiratory support equipment Monitor temp and levels of muscle strength with temperature changes. Antiemetics → ondansetron (zofran), dolasetron (anzemet), metoclopramide (reglan), scopolamine (transderm-scop), prochlorperazine *SE is constipation* Monitor HR and rhythm, cardiopulmonary status, level of CNS excitation or sedation, ability to move limbs, and n/v Miscellaneous adjuncts Dexamethasone Monitor for possible SE Dexmedetomidine (precedex) Monitor HR and rhythm and BP for possible side effects

PCA and drugs in the OR

PCA: 1. basal: constant, hands off rate 2. bolus: PRN as needed (hard to use with sleeping pt, wake up in pain so advocate for them to have basal rate) 3. basal bolus: combo Meds: decrease anxiety, decrease secretions, decrease anesthesia used (multimodal), control N/V

GI prevention interventions

PONV NPO, IV fluids, clear liquids Antiemetics/prokinetics Alternative therapy (imagery, music, acupressure, etc.) Adequate hydration and oral care is critical Assess bowel sounds/flatulence (Is the pt hungry? Passing gas?) Early mobilization (relieves gas pains)

Who is sterile? (Scrub Nurse or Circulating Nurse?)

Perioperative role: assume functions that involve either sterile or unsterile activities Scrub nurse: follow surgical hands antisepsis procedure, gowned and gloved in sterile attire and remain in sterile field Circulating nurse: remain in the unsterile field and so are not gowned and gloved in sterile attire

Sources of stress

Physiologic sources: skin burn, chronic pain, hypothermia, infectious disease, excessive noise, starvation, running a marathon, birth of a baby Emotional/psychological: diagnosis of cancer, marital problems, failing an exam, inadequate financial resources to meet needs, grieving loss of a family member, caring for a disabled child, winning or losing an athletic event, winning the lottery Positive: motivating, inspiring, helps us achieve goals Negative: headaches, an upset stomach, high blood pressure, chest pain, problems with sex and sleep, emotional problems, depression, panic attacks, or other forms of anxiety and worry - the body does not diff between bad/good and real/imaginary stress

Potential problems in the postoperative period: pain and discomfort complications

Physiological factors Psychological factors Other sources

Notes from hospital about pre-op

Pre-op: biggest problem is cardiac clearance, med reconciliation (can't be sure pt is safe otherwise) - pt is marked if lateralization by surgeon - no family in PACU unless handicap or disability or child ***anesthesiologist discharges from PACU*** - do pre-AT: pre admit test to make sure ok for surgery Post-op: complaints about positioning, sore, ache Scrubs: no jewelry, hair up in the hair net, take off shoe cover before leaving unit, boots over scrubs and shoe cover over boots Sterile: blue/green, always face sterile to sterile and nonsterile to nonsterile, move where they and you can see each other - can move to their back which is non sterile - only sterile from below collar bone to belly button, arms to 1 inch below elbow, back is not sterile - always face sterile field, arms above waist Informed consent: 1. doctor is responsible for it not you, we just witness signed paper, must have order for consent 2. must understand everything and know (RBA) risks, benefits, and alternative tx 3. if can't tell you those then doctor is responsible to

Safety in OR

Privacy, prevention of infection, and safety are key ***Time out/pre op checklist: consent, before the induction of anesthesia, ask the pt to confirm name, birthdate, ID band number, name of procedure, hospital chart ID, surgical procedure and site, and consent; wrong surgical procedure on wrong body part (sentinel event or serious reportable event) pt allergies oxygenation, fire risk (oxygen and anesthetics that are gasses so big FIRE HAZARD), exposure to blood and body fluids positioning and draping (can cause pressure ulcers, soreness) maintaining sterility

Respiratory prevention interventions

Proper patient positioning Lateral recovery position (if unconscious or n/v) Once conscious: supine position Oxygen therapy coughing and deep breathing incentive spirometry 10 x every hour (diaphragmatic/abdominal breathing) sustained maximal inspiration change position q 1-2 hrs early mobilization pain management adequate hydration (parenteral or oral) chest physical therapy

Effects of stress on health

Psychoneuroimmunology (PNI): interdisciplinary science involving the interactions among psychologic, neurologic, and immune responses Acute and chronic stress can cause immunosuppression Decreasing number and function of natural killer cells Decreasing lymphocyte proliferation Altering production of cytokines Decreasing phagocytosis Post op patients will be immunosuppressed We are not meant to remain on high alert.... Linked to leading causes of death, impaired cognitive function, and negative changes in lifestyle behaviors Long term exposure to catecholamines from excessive activation of SNS Increased r/f CV diseases Decreased control of metabolic conditions Makes us more susceptible to infection At the cellular level, stress may promote earlier onset of age related diseases Link between stress and telomere length (structure on chromosome) Chronic stress contributes to chronic illness Stress is a major factor in escalating health care costs

Endocrine assessment

Pt with DM at r/f hypo/hyperglycemia, ketosis, CV alterations, delayed wound healing, infection need serum or capillary glucose tests morning of surgery to get baseline Clarify with physician or ACP regarding insulin dose (normal or oral) & establish baseline glucose levels Pt with thyroid dysfunction hyper/hypothyroidism poses surgical risks because of altered metabolic rate Verify with ACP about giving thyroid meds Pt with addison's dz Abruptly stopping replacement corticosteroids could cause addisonian crisis Stress of surgery may require increased dose of IV corticosteroids

Immune assessment

Pt with hx of compromised immune system or use of immunosuppressive drugs can have delayed wound healing, increased r/f infx - COPD pt with hx of corticosteroid use will need to be tapered preop - uncontrolled diabetes with hyperglycemia (decr. wound healing) - know where pt is with immune system: WBC, glucose, medications

Surgical team and responsibilities

RN: perioperative nurse, use of SBAR, prepare pt for OR before they arrive Maintain safety, privacy, dignity, and confidentiality Communicate with patient and provide physical care. Scrub nurse: (OP nurse) Completes surgical hand asepsis and gowns/gloves self and other members of the surgical team Prepares instrument table and arranges sterile equipment for surgical use Assists with draping procedure Passes instruments to surgeon Maintains accurate count of surgical equipment Accepts, verifies, and reports drugs used by surgeon and/or ACP Circulating nurse: Helps prep room and ensure sterility of equipment and tables Conducts surgical "timeout" Assesses pt physical and emotional status Confirms and implements SCIP measures Checks chart and relays pertinent info to team Helps with application of monitoring devices and invasive lines Ensures pt safety and positioning Measures I&O Confirms, dispenses, and records drugs used Maintains accurate count of equipment Goes with pt to PACU Gives hand off report to PACU ns with information to relevant pt care LPN/vocational nurse/surgical tech: May fill role of scrub nurse or circulating nurse If circulating nurse is not an RN, they must have access to an RN at all times to supervise Surgeon: Pre op medical history and physical assessment, including need for surgical intervention, choice of surgical procedure, management of preoperative testing, and discussion of risks/benefits/alternatives to surgery (can be a PA) Performs procedure Patient safety/management in OR Post Op management of patient Surgeon's assistant: Physician who assists in the procedure Holds retractors to expose surgical areas and assists with homeostasis and suturing May perform some portions of the procedure under surgeon's direct supervision Registered Nurse First Assistant (RNFA): Collaborates with surgeon for optimal outcomes Prepares and uses instruments, provides exposure to surgical site, handles tissue, assists with homeostasis and suturing Anesthesiologist/CRNA: Administers anesthesia Provide care during post op recovery

Potential problems in the postoperative period: urinary complications

Retention Oliguria (however, 800-1500 ml in the 1st 24 hrs is normal) Catheter associated urinary tract infection (CAUTI)

What is the overall goal in surgical assessment of client?

SAFETY (by ID risk factors and planning care: age influences RF) - ST. John's Wart increases effects of sedatives - preop interview is most important: get pt info, provide and clarify info about surgery, and assess emotional state and readiness - do not negate pt's thoughts or intuition (can effect outcome) - they have permission to say no at any time - listen, use open ended, let them verbalize feelings, make them comfortable so they are willing to be open - Get baseline assessment (to compare before and after surgery) - Good h&p is priority with full skin assessment - skin assessment is important because certain operating positions put pressure in certain places - meet their specific cultural etc. needs such as turning to face window

Psychosocial assessment

Situational changes: fears, expectations, concerns of independence, hope, support systems, cultural, religious, socioeconomic status, living situation, financial support, anxiety around life decisions Concerns with unknown: pain, diagnosis, death, effects on daily living and sexual life if applicable (pre and post op pain mgt teaching prior to surgery, tell them what's going to happen and show them, talk about expected outcomes) - anxiety: explain all senses they may experience in the OR to help them have better understanding, knowing can decrease anxiety and increase success - managing pain that is unknown, cultural expressions are different, opioid crisis and pain management - fear: pain, altered body, anesthesia, disrupted life, diagnosis, being alone and residual effects, death, loss of control in elimination, at home - ***Hope is the pt's strongest method of coping*** Concerns with body image: scars, ostomies, mastectomies, amputations, facial reconstructions, makeup, dentures, glasses (let them wear as long as possible) Past experiences: terrible experience in hospital (determine pt response to prior, identify current perceptions); good or bad, be careful with what you say; use of herbal supplements Knowledge deficit: teaching (identify amt of info pt wants, assess pt understanding, identify accuracy of info pt knows) - r/t preop education, op, and post op; meds, activities, interventions and outcomes - do before surgery to help with anxiety after and while the pt is more relaxed and in less pain - know their meds (ones that need to be held) & be specific about NPO protocol (take drinks off bedside table after midnight etc.)

Integumentary assessment

Skin status (previous or current skin conditions - pressure ulcers/eczema/bruising) Inspect skin for rashes, boil, infx esp around planned surgical site can affect postop healing Inspect MM and skin turgor for s/s dehydration Assess skin moisture and temperature Body art such as tattoos or piercings determine IV site - albumin - allergies and reactions, armband, swelling and 3rd spacing (albumin and protein levels) - check allergies to tapes and cleaning solutions, pt with more procedures at increased risk for latex allergy b/c contact exposure, and watch those with peaches/avocado allergies -> link to latex - hydration status: turgor, urinary output, color, MM, increased BUN and normal Cr; CBC increased HCT %, increased electrolytes (know it is a volume problem)

Genitourinary assessment

Some meds are excreted through kidneys (will be affected if pt has kidney dz) Nephrotoxic drugs? What is their BUN and Cr? (increased BUN → dehydration → hypovolemic state → shock) Infx? Preexisting dz? Ability void, color/amt/characteristics of urine Pregnancy status - Check BPH

Sympathetic Nervous System- "Fight-or-Flight"

Stimulates adrenal medulla to release epinephrine and norepinephrine Sympathoadrenal response: affect of catecholamines, epinephrine and norepinephrine Prepares body for fight or flight response - Cortisol: increases glucose, potentiating effect of catecholamines on the vessels, inhibit inflam response - corticosteroids (adrenal cortex): play important role in "turning off" or blunting the stress response which if uncontrolled can become self-destructive Fight or Flight - heart: increased CO, SV, and HR increased glucose, increased O2 consumed & metabolic rate - blood vessels: constrict, increased circulation to vital organs (heart, brain, lungs) and decreased to other (dilation of skeletal muscles allow for quick movement; peripheral circulation/perfusion decr. HR and temp; increase O2 required by the heart due to dilation of heart vessels); constriction causes increase BP - lungs: increased RR, hyperventilate and put of CO2, increased r/f respiratory alkalosis r/t shallow breathing and blow off a lot of CO2, may complain of cardiac symptoms, poor oxygen supply that doesn't meed oxygen needs, no deep breaths - kidneys: cause prolonged SNS response, increased adrenaline and norepinephrine from the adrenal cortex, fight/flight - liver: causes increased production of glucose leading to increased blood sugar - GI: has slowed motility, increased r/f constipation, increased r/f ileus Ileus: small bowel shuts down Always ask if they've been passing any gas to know how GI is working You want to hear deep bowel sounds High pitched bowel sounds is sign of bowel obstruction

Potential problems in the postoperative period: surgical site infection

Surgical site/wounds Surgical site infection (SSI) Contamination of the wound Exogenous flora from environment Oral flora Intestinal flora Accumulation of fluid in the wound (impairs healing) Dehiscence (separation and disruption of previously joined wound edges)

Multimodal analgesic regimen

Two or more classes of analgesics to take advantage of various mechanisms of action. Decrease adverse effects from high doses of analgesics by combining multiple drugs at a lower dose neuropathic pain not well controlled by opioids, needs multimodal approach acute, post-op pain: opioid + non opioid and/or antiseizure drug - may also use regional anesthesia and continuous peripheral neural blockade - factors influencing what multimodal approach to use: age, type of surgery, risk for developing chronic pain, and coexisting conditions - can also be used to treat chronic or persistent pain or neuropathic pain Adjuvants: - corticosteroids (decr. immune, dyspepsia, fluid retention, act through same final pathways as NSAIDs so don't give at same time) - antidepressants in inhibitory and reuptake of NE and Epi and help with neuralgia pain, IBS, PTSD - anti-seizure drugs: dilantin, tegrotol Na blockers for nerve pain (DM) - clonidine: adrenergic piece with pain managements (benzo) - local anesthetics: epidurals, -cain, help with itching - cannabinoids: help with N/V and incr. appetite with pts in chronic pain/CA

Stress factors

Type Duration (Acute or chronic) Intensity (mild, mod, severe) Internal influences (age, health status, personality, previous experience with stress) Resilience: resourceful, flexible, and having good problem solving skills Hardiness: courage and motivation to turn potential disaster into opportunities for personal growth Attitude: helps prevent disease and prolong life Being optimistic: helps avoid illness and increases speed of recovery External influences (cultural and ethnic influences, socioeconomic status, social support, timing of stressors)

process information

admission area preop holding area, OR, and PACU caregivers can usually stay in preop holding area until surgery caregivers will be able to see patient after discharge from the PACU or possible in PACU once pt is awake ID of any technology that may be present on awakening, such as monitors, central lines, sequential compression devices encourage caregivers to ask questions and express any concerns OR staff will update caregivers during surgery and when surgery is completed surgeon will usually talk with caregivers after surgery

Pain and discomfort prevention interventions post-op

behavioral modalities patient teaching regarding how to report pain single modalities multimodal analgesia (recommended when possible to achieve better pain relief with fewer SE, use of two or more analgesics with diff MOA ex. NSAID and opioid) PCA

Meds that affect stress/coping

beta blockers: slow heart rate and bronchoconstriction; so may not respond to stress with increased heart rate, pt may be in more stress than we see on their heart rate

Definitions of pain

complex, multidimensional experience that can cause suffering and decreased quality of life. whatever the person experiencing the pain says it is, existing whenever the person says it does an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage

Basic principles of pain management

follow the principles of pain assessment (listed above) Use a holistic approach to pain management Every person deserves adequate pain management Base the treatment plan on the patient's goals Use both drug and non drug therapies When appropriate, use a multimodal approach/alternative to analgesic therapy Address pain using an interprofessional approach Evaluate effectiveness of all therapies to ensure that they are meeting the patient's goals Prevent and/or manage medication side effects. Incorporate patient and caregiver teaching throughout assessment and treatment

Male vs. Female pain & elderly & cultures & spiritual distress (JCO requirements)

higher regardless of gender if have history of sexual or physical abuse Elderly: barriers to pain assessment, fear taking opioids or believe pain to be normal so don't complain - slower metabolism of drugs, greater risk for higher blood drug levels and adverse effects - start low and go slow - NSAIDs = high frequency of GI bleeding - many drugs so more drug interactions - cognitive impairment and ataxia (must titrate drugs) Different from culture to culture: - help patients better understand and tolerate their pain - pts suffering may need more help with control - can help harness the conscious mind and perception of pain (how cultures are so different) Spiritual: - The spiritual distress they are in can affect their expression and level of pain, their "pain" may mean that they are simply in a state of spiritual distress and not in actual physical pain - pain is not always physical pain, sometimes those on the call light all the time, "life hurts" and only way to express it is displayed in physical pain, What is really hurting here? - sometimes just sitting there and giving company can help pain go away - anxiety and suffering intensify pain, figure out where is the stress, pain as the 5th vital sign - too much emphasis on controlling all of the pain, help them understand that life is painful, it may hurt and there will be pain but it isn't reasonable to be able to be completely without pain - (JCO says we must follow up and monitor pts every hour, know side effects to assess for); acute can turn into chronic pain

Potential problems in the postoperative period: temperature alteration complications

hypothermia/shivering Fever Malignant hyperthermia

Neurologic prevention interventions

monitor oxygen levels with pulse oximetry oxygen therapy pain management reversal agents (Phase 1) assess for anxiety and depression alcohol protocols fluid and electrolyte balance adequate nutrition Sleep proper bowel and bladder functioning monitor mobility status and activity status for safety

urinary prevention interventions

monitor urine output adequate hydration remove urinary catheter when no longer indicated normal positioning of pt for elimination bladder scan/straight catheter per orders - pt on IV, meds that are nephrotoxic (antibiotics), measure output with hat even when foley is out!

Physiological response to stress

our perception of the stressors determines whether or not they cause stress weakened immune system leading to increased r/f getting sick increased cardiac output, increased blood glucose levels, increased oxygen consumption, increased metabolic rate increased HR and BP, hyperventilation, headache - cerebral cortex: past experiences and future consequences - limbic system: emotions and behavior - reticular formation: RAS, alertness - hypothalamus: adaption to stress, regulate function of sympathetic and parasympathetic in autonomic NS