AHN Ch 2

Patient teaching for incentive spirometry

- After incentive spirometry exercises, patients should practice controlled coughing techniques - Teach patients to examine their sputum for consistency, amount, and color changes - Before discharge, have patients return a demonstration of the correct procedure for use - Administer breathing treatments before patients' meals to prevent nausea and vomiting

Urinary Function

- Assess the bladder area ever 2 hours for distention and changes in renal function. - It routinely takes 6 to 8 hours for voiding to occur after surgery. If patients do not void within 8 hours, catheterization may be necessary, but used be a last measure. - A urinary output of 30 mL per hour is considered acceptable postoperatively.

Gastrointestinal Preparation

- At midnight before surgery, the patient is usually placed on nothing by mouth (NPO) status; this ensures the GI tract is empty when the patient is anesthetized, thereby decreasing the chance of vomiting or aspirating emesis after surgery - Clear liquid may be taken up to 3 hours before surgery - Oral care - Wet cloth on the lips helps relieve dryness - If patients need to be hydrated or requires special IV medications, the physician may order parenteral fluids or medication

Gastrointestinal Status Postoperative

- Because anesthesia and surgical manipulation slow peristalsis, it may take 3 or 4 days for bowel activity to return. - Normal peristalsis is indicated by hearing 5 to 30 gurgles per minute - Listen for bowel sounds in all four quadrant for 1 minute

Incision

- Dressing are not changed but are reinforced during the first 24 hours. - To measure the amount of drainage, circle the drainage markings on the dressing and write the time and date - Dehiscence may occur 3 days to more than 2 weeks postoperatively - Wound separation in the first 3 days is usually related to technical factors, such as the sutures. Separation from 3 to 14 days postoperatively is usually associated with postoperative complications such as distention, vomiting, excessive coughing, dehydration, or infection. - Wound separation after 2 weeks is usually associated with metabolic factors such as cachexia, hypoproteinemia, increased age, malignancy, radiation therapy, and obesity. - Tension on the abdomen may be decreased by placing the patient in Fowler's position with the knees slightly flexed

Common Fears Associated with Surgery

- Fear of loss of control - Fear of the unknown - Fear of the anesthesia - Fear of pain or inadequate postoperative analgesia - Fear of death - Fear of separation from the usual support group - Fear of disruption of life patterns - Fear of change in body image and mutilation - Fear of detection of cancer

Fluid and Electrolytes

- For at least the first 24 to 48 hours after surgery, the body retains fluids as part of the stress response to trauma and the effect of anesthesia - Sodium and potassium depletion can occur after surgery as a result of the loss of blood or blooody fluids during surgery or the loss of GI secretion because of vomiting and NG tubes - Potassium is also lost during catabolism, especially after severe trauma or crush injuries - Loss of gastric secretions can result in chloride loss, producing metabolic alkalosis - Electrolytes are often added to the IV solution in the form of potassium chloride (KCI), which may irritate the vein when administered by an IV route - As oral fluids are introduced, encourage patients to drink small amounts frequently (6 to 8 ounces per hour) and without straw - If nausea and vomiting persist, an antiemetic such as promethazine (Phenergan), benzquinamide (Emete-Con), or prochlorperazine (Compazine) is usually ordered to be administered intravenously or rectally.

Factor influencing the risk for latex allergy response

- History of anaphylactic reaction of unknown etiology during a medical or surgical procedure - Multiple surgical procedures - Food allergies - A job with daily exposure to latex - History of reactions to latex - Allergy to poinsettia plants - History of allergies and asthma

Venous Stasis

- Immediate postoperative hypoventilation can result from drugs, incision pain, obesity, chronic lung disease, or pressure on the diaphragm .- Inadequate ventilation leads to hypoxemia - Help patient turn, cough, and breath deeply every 1 to 2 hours until the chest is clear - If patient feels chest pain or has a fever, productive cough, or dyspnea, atelectasis or pneumonia may be developing. - If respiratory complications develop, the physician may order respiratory therapy to provide intermittent positive pressure breathing (IPPB) treatments to deliver a mixture of air and oxygen; medication can be added to enhance respirations

Ventilation

- Immediate postoperative hypoventilation can result from drugs, incision pain, obesity, chronic lung disease, or pressure on the diaphragm. - Inadequate ventilation leads to hypoxemia - Help patient turn, cough, and breath deeply every 1 to 2 hours until the chest is clear - If patient feels chest pain or has a fever, productive cough, or dyspnea, atelectasis or pneumonia may be developing. - If respiratory complications develop, the physician may order respiratory therapy to provide intermittent positive pressure breathing (IPPB) treatments to deliver a mixture of air and oxygen; medication can be added to enhance respirations

Latex allergy is classified in three categories:

- Irritant reaction (actually a nonallergic reaction) - Type IV allergic reactions ( cell-mediated response to the chemical irritants found in latex products) - Type I allergic reactions (immunoglobulin E mediated systemic reaction that occurs when latex proteins are touched, inhaled, or ingested)

Later Postoperative Phase

- Monitor vital signs and make general assessment using the "times-four" factor. The times-four gauge is the maximal time that should elapse between assessments - Until the patient is fully conscious, do not place a pillow under the head - Nausea and vomiting are normal in the first 12 to 24 hours - Frequently the patient remains on NPO status for the first few hours after surgery. - A significant drop in blood pressure, accompanied by an increased heart rate, may indicate hemorrhage, circulatory failure, or fluid shifts

Possible Cause of Postoperative Shock

- Movement of patient from operating table to gurney - Patient being jarred during transport - Reactions to drugs and anesthesia - Loss of blood and other body fluids - Cardiac dysrhythmias - Cardiac failure - Inadequate ventilation - Pain

Older Adults in Undergoing Surgery

- Older adults undergoing surgery have higher morbidity and mortality rates than younger people - Surgery places a greater stress on older people than on younger people. - Older patients tend to recover more slowly from surgery compared with younger patients. - Risks of aspiration, atelectasis, pneumonia, thrombus formation, infection, and altered tissue perfusion are increased in the older adult - Disorientation or toxic reactions can occur in the older adult after the administration of anesthetics, sedatives, or analgesics. - Preoperative and postoperative teaching may require extra time. - When communicating with older adult patients, be aware of any auditory, visual, or cognitive impairment that may be present

Responsibilities of the Scrub Nurse

- Performs surgical hand scrub - Dons sterile gown and gloves aseptically - Arranges sterile supplies and instruments in manner prescribed for procedure - Checks instruments for proper functioning - Counts sponges, needles, and instrument with circulating room - Gowns and gloves surgeons as they enter operating room - Assists with surgical draping of patient - Maintains neat and orderly sterile field - Corrects breaks in aseptic technique - Observes progress of surgical procedure - Hands surgeon instruments, sponges, and necessary supplies during procedure - Identifies and handles surgical specimens correctly - Maintains count of sponges, needles, and instruments so none will be misplaced or lost in wound

Informed consent

- Permission to perform a specific test or procedure. - Must be clear, the risk explained, expected benefits identified, and consequences or alternatives for the presenting problem stated - Witnesses are required to meet the state's legal requirements - Should not be obtained if the patient is disoriented, unconscious, mentally incompetent, or, in some agencies, under the influence of sedatives - Occasionally telephone permission may be obtained, if patient may not be able to give consent for surgery - If patient's life is in danger and family members cannot be located, the surgeon may legally perform surgery - If family member object to surgery, a court order may be obtained for procedure

Responsibilities of the Circulating Nurse

- Prepares operating room with necessary equipment and supplies and ensures that equipment is functional - Arranges sterile and unsterile supplies; opens sterile supplies for scrub nurse - Sends for patient at proper time - Visits with patient preoperatively; explains role, identifies patient, verifies operative permit, and answers any questions- Performs patient assessment - Confirms patient assessment - Checks medical record for completeness - Assists in safe transfer of patient to operating room table - Positions patient on operating room table in accordance with type of procedure and surgeon's preference - Places conductive pad on patient if electrocautery is to be used- Counts sponges, needles, and instruments with scrub nurse before surgery - Assists scrub nurse and surgeons by tying gowns - May prepare patient's skin - Assists scrub nurse in arranging tables to create sterile field - Maintains continuous astute observations during surgery to anticipate needs of patient, scrub nurse, surgeons, and anesthesiologist - Provides supplies to scrub nurse as needed - Observes sterile field closely for any breaks in aseptic technique, and reports accordingly - Care for surgical specimens according to institutions policy - Documents operative record and nurse's notes - Counts sponges, needles, and instruments when closure of wound begins - Transfers patient to gurney for transport to recovery area - Accompanies patient to the recovery room and provides a report

Skin Preparation

- Shaving the hair before surgery creates microscopic cuts that increase the risk of surgical site infection. - The CDC and Prevention strongly recommends not removing hair at all unless it would interfere with the surgery. - Shave close to the actual time of the surgical procedure to decrease the time for growth of bacteria and lower the potential for infection. - Scrub the skin thoroughly with a detergent solution and then apply an antiseptic solution to kill more adherent and deeper residing bacteria. The surgeon may place a transparent sterile drape directly over the skin before making an incision.

Malignant hyperthermia

- The PACU nurse must be aware that it can occur in the PACU and repeatedly assess the patient for signs of this condition. It is a genetic disorder characterized by uncontrolled skeletal muscle contractions leading to potentially fatal hyperthermia. It occurs in patients predisposed to the disorder when they receive a combination of certain anesthetic agents. Unless the event is stopped and the body is cooled, death results

Controlled Coughing Technique

- The home health nurse may need to reinforce the importance of coughing one or two times an hour during waking hours for the patient at home - Instruct the patient to cough instead of just clearing the throat; assure the patient that coughing will not injure the incision - After brain, spinal, head, neck, or eye surgery, coughing is often contraindicated because of a potential increase in intracranial pressure. It is also contraindicated for patients having cataract surgery. - Patients frequently ambulate within a few hours of surgery to return cardiovascular and respiratory functions to normal more quickly

Delegation Considerations in Perioperative Nursing

- The skills of assessment that are part of preparing the patient for surgery require the critical thinking and knowledge application unique to a nurse. Assistive personnel (AP) may obtain vital signs and weight and height measurements. - The skills of preoperative teaching require the critical thinking and knowledge application unique to a nurse. For this skill, delegation is inappropriate. AP can reinforce and assist patients in performing postoperative exercises. - Coordinating the patient's preparation for surgery requires the critical thinking and knowledge application unique to a nurse. However, AP may administer an enema or douche; obtain vital signs; apply antiembolic stockings; and assist patient in removing clothing, jewelry, and prostheses. - The skills of sterile gowning and gloving can be delegated to a surgical technologist or the nurse who has acquired the proper skills. - The skill of initiating and managing postoperative care of the patient requires the critical thinking and knowledge application unique to a nurse. AP may obtain vital signs, apply nasal cannula or oxygen mask, and provide basic comfort and hygiene measures

When a patient appears to be going into shock, take the following steps

1. Administer oxygen or increase its rate of delivery 2. Raise the patient's legs above the level of the heart 3. Increase the rate of IV fluids (unless contraindicated because of fluid excretion problems) 4. Notify the anesthesia provider and the surgeon 5. Provide medications as ordered 6. Continue to assess the patient and response to intervention

A for Positive Expiratory Pressure therapy and "huff" coughing

1. Instruct patient to assume semi-Fowler's or high Fowler's position, and place noseclip on patient's nose. (Promotes optimum lung expansion and expectoration of mucus) 2. Innstruct patient to place lips around mouth piece and (a) take a full breath and exhale 2 or 3 times longer than inhalation and (b) repeat this pattern for 10 to 20 breaths. 3. Remove device from mouth, and have patient take a slow, deep breath and hold for 3 seconds. (Promotes lung expansion before coughing) 4. Instruct patient to exhale in quick, short, forced "huffs" ("Huff" coughing, or forced expiratory technique, promotes bronchial hygiene by increasing expectoration of secretions.)

NA for Incentive spirometry

1. Instruct patient to completely cover mouthpiece with lips (use a noseclip if patient is unable to breathe through the mouthpiece) and to (a) inhale slowly until maximum inspiration is reached, (b) hold breath 2 or 3 seconds, and (c) slowly exhale 2. Instruct patient to relax and breathe normally for a short time. (Prevents patient from hyperventilating and prevents fatigue) 3. Instruct patient to relax and breathe normally for a short time. (Promotes maximum lung expansion) 4. Offer oral hygiene after spirometry is completed. (Patients often find this refreshing)

NA for Postoperative Breathing Techniques

1. Place pillow between patient and bed or chair 2. demonstrate taking slow, deep breaths. Avoid moving shoulders and chest while inhaling. Inhale through nose. (Prevents panting and hyperventilation. Moistens, filters, and warms inhaled air.) 3. Hold breath for a count of three, and slowly exhale through pursed lips. (Allows for gradual expulsion of air.) 4. Repeat exercise three to five times. 5. Instruct patient to take 10 show, deep breaths every 2 hours until ambulatory. (Helps prevent postoperative complications.) 6. If there is an abdominal or chest incision, instruct patient to splint incisional area using pillow or bath blanket during breathing exercises. (Provides support and additional security for patient.)

NA for Controlled Coughing

1. Take several deep breaths. (Deep breaths expand lungs fully so that air moves behind mucus and facilitates effect of coughing.) 2. In hale through nose. 3. Exhale through mouth with pursed lips. 4. Inhale deeply again and hold breath for count of three 5. Cough two or three consecutive times without inhaling between coughs. (Consecutive coughs remove mucus more effectively and completely than one forceful cough.)

Preoperative information helps reduce

1. anxiety 2. the amount of anesthesia needed 3. postsurgical pian 4. corticosteroid production 5. speeds wound healing preoperative teaching is provided 1 or 2 days before surgery.

ABCS

A - Airway B- Breathing C - Consciousness C - Circulation S - System Review

ABCDEF

A - Allergy to medication, chemicals, and other environmental products such as latex. All allergies are reported to anesthesia and surgical personnel before the beginning of surgery. Place an allergy band on the patient's arm immediately. B - Bleeding tendencies or the use of medications that deter clotting, such as aspirin or products containing aspirin, heparin, or warfarin sodium. Herbal medications may also increase bleeding times or mask potential blood-related problems. C - Cortisone or steroid use D - Diabetes mellitus, a condition that not only requires strict control of blood glucose levels but is also known to delay wound healing E - Emboli. Previous embolic events (such as lower leg blood cloths) may recur because of prolonged immobility F - Fighting ability. patients whose immune systems are suppressed are at a much higher risk for development of postoperative infection and are less capable of fighting that infection

Paralytic ileus

A decrease in or absence of intestinal peristalsis that may occur after abdominal surgery, peritoneal trauma, severe metabolic disease, and other conditions

Incentive Spirometry

A procedure in which a device (spirometer) is used at the bedside at regular intervals to encourage a patient to breathe deeply

Induction phase

Administration of agents and endotracheal intubation

Conscious sedation

Administration of drugs that depress the central nervous system or provide analgesia to relieve anxiety or provide amnesia during surgical diagnostic procedures. Used for procedures that do not require complete anesthesia but rather a depressed level of consciousness. Advantages of conscious sedation include adequate sedation and reduction of fear and anxiety with minimal risk, amnesia, relief of pain and noxious stimuli, mood alternation, elevation of pain threshold, enhanced patient cooperation, stable vital signs, and rapid recovery.

Factors affect the individual's ability to tolerate surgery

Age Physical conditionNutritional factors (Carbohydrates and fats are the primary energy producers. Protein is essential to build and repair body tissue)

Prosthesis

An artificial replacement for a missing part of the body

Emergence phase

Anesthetics are decreased and the patient begins to awaken. Because of the short half-life of today's medications, emergence often occurs in the OR

Prevention of DVT

Antiembolism stocking, a Jobst pump, or sequential compression devices (SCDs) with intermittent external pneumonic compression system

Delegation Considerations in Perioperative Nursing

Box 2.2

Lysis

Destruction of dissolution eg: lysis of adhesions - removal of adhesions

-oscopy

Direct visualization by a scope eg: cystoscopy - direct visualization of the urinary tract by means of a cystoscope

Ablative

Excision or removal of diseased body part

-pexy

Fixation of eg: cecopexy - fixation or suspension of the cecum to correct its excessive mobility

Singultus

Hiccup. It is an involuntary contraction of the diaphragm followed by rapid closure of the gottis. It results from irritation of the phrenic nerve. It is seen most often in men

Preanesthesia Care unite

Holding area - Nurse completes the preoperative preparations - Nurse or anesthesiologist inserts an IV catheter into the patient's vein to establish a route for fluid replacement and IV medications - The temperature in the OR is usually cool, so offer the patient an extra blanket for warmth and relaxation. - The patient's stay in the holding area is brief

Cachexia

Ill health, malnutrition, and wasting as a result of chronic disease

Common Surgical Setting

Inpatient One-day (same-day surgery) Outpatient Short-stay surgical center (Surgicenter) Short-stay unit Mobile surgery units

Local anesthesia

Involves loss of sensation at the desired site. It is commonly used for minor procedures performed in ambulatory surgery.

Urinary Catheter

It is removed 1 or 2 days postoperatively to reduce the chance of bladder infection. Once it is removed, encourage the patient to drink 8 ounces of fluids per hour while awake unless contraindicated.

Volume-oriented spirometer

Known as volume of inspiration. Encourage the patient to breathe with normal inspired capacity

Nerve Block

Local anesthetic is injected into a nerve, blocking the nerve supply to the operative site.

IV regional anesthesia (Bier block)

Local anesthetic is injected via an IV line into an extremity below the level of a tourniquet after blood has been withdrawn. The drug is allowed to infiltrate only tissues in the intended surgical area. The extremity is pain free while the tourniquet is in place. Advantages include a short onset and short recovery time. However, the tourniquet may be inflated for only 2 hours or tissue damage will occur

-otomy

Opening into eg: thoracotomy - surgical opening into the thoracic cavity

- ostomy

Opening made to allow the passage of drainage eg: ileostomy - formation of an opening of the ileum onto the surface of the abdomen for passage of feces

What is elective surgery?

Planned for correction of a nonacute problem

-plasty

Plastic surgery eg: mammoplasty - reshaping of the breasts to reduce, lift, reconstruct

Maintenance phase

Position the patient, preparing the skin for incision, and performing the surgery. Appropriate levels of anesthesia are maintained during this phase.

Evisceration

Protrusion of an internal organ through a wound or surgical incision, especially in the abdominal wall

Epidural anesthesia

Safer procedure than spinal anesthesia because the anesthetic agent is injected into the epidural space outside the dura mater and the depth of anesthesia is lighter. Epidural anesthesia blocks sensation in the vaginal and perineal areas and thus is often used for obstetric procedures. The epidural catheter may be left in so that the patient can receive medication via continuous epidural infusion after surgery

This is the area of medicine that addresses diseases, conditions, and traumatic injuries that are difficult or impossible to treat only with medicine.

Surgery

Palliative

Surgery for relief or reduction of intensity of disease symptoms; will not produce cure

anastomosis

Surgical joining of two ducts or blood vessels to allow flow from one to another; to bypass an area (Billroth I - joins stomach and duodenum)

-ectomy

Surgical removal of eg: cholecystectomy - removal of the gallbladder

-orrhaphy

Surgical repair of eg: herniorrhaphy - repair of a hernia

Preoperative Considerations for commonly ingested herbs

Table 2.3

Surgical Effects on Body Systems

Table 2.4

Spinal anesthesia

The anesthesiologist performs a lumbar puncture and introduces local anesthetic into the cerebrospinal fluid in the subarachnoid space. Anesthesia can extend from the tip of the xiphoid process down to the feet. Spinal anesthesia is often used for lower abdominal, pelvic, and lower extremity procedures; urologic procedures; or surgical obstetrics

Dehiscence

The separation of a surgical incision or rupture of a wound closure

Flow-oriented inspiratory spirometer

This type of incentive spirometer is inexpensive and measures inspiration. In contains one or more clear plastic cylinder chambers that contain freely movable, colored, lightweight plastic balls.

15 to 30 minutes

Vital Signs, dressings, and tubes are assessed until the patient is awake and stable

What is anesthesia?

absence of all sensation, including pain

what is postoperative phase?

after surgery

ex. of ablative

amputation, removal of appendix, cholecystectomy

what are some medications that are not stopped and are given with a sip of water the morning of surgery ?

antiseizure and cardiac drugs

what is preoperative phase?

before surgery

what do carbohydrates, proteins, and fat do?

carbohydrates and fats are the primary energy producers and protein is essential to build and repaid body tissue

what does the body use to supply energy producing glucose to its cells?

carbohydrates, proteins, and fat

what is regional anesthesia?

causes loss of sensation in an area of the body and is used for some surgical procedure and pain management. Pt does not lose consciousness but is usually sedated

what is atelectasis?

collapse of lung tissue

ex of palliative

colostomy, debridement of necrotic tissue

what is polypharmacy?

concurrent use of multiple medications

what is infarct?

dead tissue

What are various purposes of performing surgery?

diagnostic, ablative, palliative, reconstructive, curative, preventative, transplant, constructive, and cosmetic

what is intraoperative phase?

during surgery

What is surgery classified as?

elective, urgent, or emergent

what are some perceptions that need to be evaluated that might influence a patients perioperative period

emotion, behavior, and support systems

what are benefits to patient teaching before surgery?

it reduces pts anxiety associated w/ fear of the unknown, the amount of anesthesia needed, postsurgical pain, and corticosteriod production

what is embolus?

moving blood clot

what is emergent surgery?

performed immediately to save the individuals life or to preserve the function of a body part or system.

what is incentive spirometer (IS)?

procedure in which a device is used at the bedside at regular intervals to encourage a patient to breathe deeply

What is general anesthesia?

produces amnesia, analgesia, muscle paralysis, and sedation reversible. - used for major surgery requiring extensive tissue manipulation.

What is an urgent surgery?

required to keep additional health problems from occurying

what is thrombus?

stationary blood clot

what is perioperative?

time period of a patient's surgical procedure. It commonly includes ward admission, anesthesia, surgery, and recovery