Ch 9 Per-op
Other adult pts are at greater risk for dehydration because
- their fluid reserves are lower than those of young or middle-age adults ***Hemodynamic monitoring of older adults pts and pts with cardiac disease receiving IV fluids is essential
What is the nurse's role in preoperative
- to clarify facts that have been presented by the surgeon and dispel myths that the pt, family, or caregiver may have about the surgical experience - verify that the consent form has been signed, dated, and timed - witness to signature ( not to the adequacy of pt' understanding, which is the surgeon's responsibility)
The length of stay in PACU depends on
- type of surgery - type of anesthesia - any complications - the pt's responses
After gastric surgery do Not remove or irrigate the NG tube
- unless ordered
During the nursing assessment before surgery
- validate - clarify - reinforce information the pt has received from the surgical team
Pts who cannot write may sign with an "X" , which must be
- witnessed by two people, one of whom can be the nurse
For a life-threatening situation in which the pt cannot give consent, and every effort has been made to contact the person with medical power of attorney (w/o success)
- written consultation with at least two health care providers not associated with the case may be requested by the surgeon
Respiratory status is established by
- age, smoking hx ( including exposure to secondhand smoke), and any chronic illness
The time provided for assessment depends on
- agency policy - pt condition - type of surgery that will be performed
A respiratory rate of less than 10 bpm indicate
- anesthetic or opioid analgesic-induced respiratory depression
Prophylactic antibiotics
-.given 1 hour prior to surgery
When the pt is admitted to the med-surg unit floor following surgery, immediately
- assess for a patent airway ***Spo2 = should be above 95% or at presurgical baseline **check lungs = q4h during first 24 hrs following surgery and then every 8 hrs , or per agency policy
Factors that increase risk for wound contamination and SSI (Surgical Site Infection) include :
- bacteria found in hair follicles - disruption of the normal protective mechanisms of the skin - nicks in the skin
Prevention of respiratory complications postop
- breathing exercises - IC - coughing and splinting
Challenges in assessing pain in the older adult pt include
- communication difficulty - cognitive deficit - comorbidities - stoic character - reluctance to report pain
Opioids , benzodiazepines, and barbiturates can cause
- confusion, apprehension, and/or restlessness
Dentures during surgery
- decision by the anesthesiologists - may or may not be removed - may be left in place - to provide a snug fit of the bag-mask
Hypokalemia
- deficient potassium in the blood - increases risk for toxicity if the pt is taking digoxin - slows recovery from anesthesia - increases cardiac irritability
unless pillow support is ordered,
- do not place pillows under the knees and do not raise the hatch because this position restrict circulation and increase the risk of VTE
A pulse deficit (difference between the apical and peripheral pulses) occurs indicate
- dysrhythmias
Alert box pg 171 A hand-off report that meets The Joint Commission's National Safety Goals requires
- effective communication between the anesthesia provider, circulating nurse, and PACU or (ICU) nurse
Surgical pts must be monitored at all times for the cluster of
- elevated co2 level - decreased oxygen saturation - tachycardia **to identify symptoms of malignant hyperthermia (MH) *** if these changes begin , respond by alerting the surgeon and anesthesia provider immediately
Hx The nurses communication about the pts surgery takes place
- face-to-face in the surgeon's office - preadmission or admission office of a hospital - inpatient unit on a floor - via telephone - conference call - via internet
Urgency of Surgery Elective surgery examples
Planned for correction of a nonacute problem Such as : cataract removal Hernia repair Hemorrhoidectomy Total joint replacement
Phase 2 of post anesthesia care
- focus on preparing the pt for care in an extended-care environment such as medical-surgical unit, step-down unit, skilled nursing agency, or home ... can occur in PACU - pt discharge from this phase when = presurgical LOC has returned, oxygen saturation is at baseline, and VS are stable
Imaging Assessment A chest X-ray may be ordered before surgery
- for pts with a hx of respiratory problems
postoperative leg exercises pg 167 - study
Postoperative Leg Exercises help to prevent blood clots which cause inflammation of the vessel. Encourage patients to perform these exercises every one to two hours while awake until the patient can ambulate
Symptoms of malignant hyperthermia include
- high fever - muscle rigidity of the jaw and upper chest - tachycardia - tachypnea - hypertension - arrhythmias - hyperkalemia - metabolic and respiratory acidosis - cyanosis - skin mottling - myoglobinuria ( muscle protein in the urine due to rhabdomyolysis
Some surgical procedures that are specific, such as left, right, or bilateral, require
- identification before surgery
Sudden swelling in one leg accompanied by a dull ache in the calf ( that becomes worse with ambulation)
- is a classic assessment finding of VTE caused by DVT ***report findings immediately to the surgeon
Phase 3 of post anesthesia Care
- known as extended-care environment - occurs in hospital unit or in the home
Pt with type 1 DM or insulin-treated type 2 diabetes who are to have morning surgery that is short (under 2 hours) and non-complex
- may continue their subQ insulin
The usual dosage for hydromorphone is
- much smaller than that of morphine
Drugs during periopoerative phase to reduce stress in the heart
- nitroglycerin, beta blockers, and antibiotics
Nurse Preop Role
- nurse functions as educator , advocate, promoter of health and safety
Minimizing Anxiety
Preoperative teaching Encourage communication Promote rest Use distraction Teach family members
VTE or DVT can lead to a PE. If the blood clot breaks off and travels to the lungs. Always assess for VTE before surgery. Risk factors associated with the development of VTE include:
- obesity - age 40 yrs or older - cancer; spinal cord; hip fracture; total hip or total knee replacement surgery - decreased mobility or immobility - hx of VTE, DVT, PT, varicose veins, or edema - oral contraceptives - smoking - decreased cardiac output
Simple surgical examples
- only the most overtly affected areas involved in the surgery Such as; Simple or partial mastectomy
Hyperkalemia
increased potassium in the blood, increases risk for dysrhythmia with use of anesthesia
Preoperative care focuses on
- preparing the pt for the surgery and ensuring safety Includes: - assessing pt knowledge and educational needs - implement interventions needed before surgery to reduce anxiety and complications - promote pt adherence to the treatment plan after surgery
Completing an assessment and gathering data should take place in
- private setting to ensure the pt's confidentiality is protected, regarding setting _ privacy increases the pt's comfort with the interview process and may help reduce the stress associated with surgery
Postoperative Patient Preparation
- remove most clothing; provide gown - leave valuables with family or lock up - tape rings in place if cannot be removed - ensure pt is wearing ID band - remove : dentures, prosthetic devices - hearing aids - contact lenses - finger nails - artificial nails - all jewelry
Prosthetic devices such as artificial eyes and limbs
- removed and given to family or caregiver or safely stored - same for contacts, and wigs
Unused Blood Products
- returned to the collection center l
Postop phase begins and ends when
- starts with completion of the surgical procedure - transfer of the pt to a specialized area such as PACU or an ICU *** phase end extend beyond discharge from the hospital until activity restrictions have been lifted
Monitor surgical incision q8h to recognize an impending evisceration. If a surgical wound evisceration occurs, respond by
- staying with the pt while calling for another nurse to immediately notify the surgeon and/or Rapid Response Team
if pt is not capable of giving consent and has no designated medical power of attorney
- the court can appoint a legal guardian to represent the pt's best interest
The true indicator of Intestinal activity is
- the passage of flatus or stool
Complications from use of opioid analgesics include
+Respiratory depression +Hypotension +Nausea +Vomiting +Constipation *** monitor BP every 15-30 mins
Physical Assessment s/s Anxiety increases
- BP, pulse, and RR
Some older pts may have poor nutrition because of chronic illness, diuretic or laxative use, poor dietary planning or habits ,anorexia, disinterest in food, or financial limitations. Indications of poor fluid intake or nutrition status include:
- Brittle nails - Muscle wasting - Dry, or flaky skin, decreased skin turgor, and hair changes (e.g dull sparse, dry) - Orthostatic (postural) hypotension - Decreased serum protein levels and anormal serum electrolyte values
All pts between ages 40 to 45 must have an
- ECG before surgery *** this provides baseline information on new or existing cardiac problems
Action Alert p.173
- Evaluate all pts for VTE risk, and ensure that prophylactic measures are in place. These may include antiembolism stockings, pneumatic compression devices, leg exercises, early ambulation, and/or drug therapy
Pg. 159 Patient-Centered Care: Older Adult Considerations When planning care for preop older adults, recognize that these pts may have
- Greater incidence of chronic illness (e.g. HTN, DM) - Greater incidence of malnutrition and dehydration - More allergies - An increased number of abnormal laboratory values (anemia, low albumin level) - Increased incidence of impaired self-care abilities - Inadequate or absent support systems - Decreased ability to withstand the stress of surgery and anesthesia - Increased risk for cardiopulmonary complications after surgery - Risk for a change in mental status when admitted (e.g r/t unfamiliar surroundings, change in routines, drugs) - Increased risk for falls and resultant injury - Mobility changes that affect recovery efforts
Abnormal xrays alert thr surgeon to conditions such as
- HF, cardiomyopathy, pneumonia, or infiltrates that may cause cancellation or delay of surgery
Analysis: Interpreting The collaborative problems for preop pts are
- Knowledge deficit r/t unfamiliarity with surgical procedures and preparation - Anxiety r/t new or unknown experience, possible of pain and possible surgical outcomes
Analysis cues and prioritize hypotheses The priority collaborative problems for preoperative pts are
- Need for health teaching due to unfamiliarity with surgical procedures and preparation - Anxiety due to fear of a new or unknown experience, pain and/or surgical outcomes
The choice of lab testing before surgery varies and depends on the pt's age, medical hx , and type of anesthesia planned. The most common tests include:
- UA - Blood type and screen - CBC (H&H) - Clotting studies (PT, INT, aPTT) - Metabolic panel (serum glucose, and serum proteins) - Pregnancy test for female pt
Lab assessment
- UA -,Blood tote and screen - CBC of H&H - Clotting studies (PT, INR, aPTT) - Electrolyte levels - Serum creatinine level - Pregnancy test - Chest x-ray - ECG
Extremely elevated temperature as high as 112.2*F (44*C)
- a late sign of (MH ) malignant hyperthermia = survival depends on early Dx and immediate action of the entire surgical team **Dantrolene sodium = a skeletal muscle relaxant - only drug specifically approved for treatment of MH
System Assessment
-Cardiovascular system = CAD, MI, within 6 months before surgery, angina, HTN, dysrhythmias -Respiratory system = chronic respiratory problems = smoking increases carboxyhemoglobin, blood level, decreases oxygen delivery -Renal/urinary system = kidney impairment Inhibits drugs/anesthetic agent excretion -Neurologic system = determine baseline = assess LOC, ability to follow commands -Musculoskeletal system = -Nutritional status = malnutrition and obesity increase surgical risk -Psychosocial assessment
Preoperative Phase
-begins when the patient is scheduled for surgery and ends at the time of transfer to the surgical suite
Decreased BP and pulse pressure and abnormal heart sounds indicate?
-cardiac depression, fluid volume deficit, shock, hemorrhage, or the effects of drugs
preop
begins with decision to have surgery, lasts until pt is transferred to the operating room or procedural bed, consent must be given to whoever gives surgery as the nurse witnesses make sure good hygiene and NPO status teach client about recovery nurse completes checklist
Splinting of the Surgical Incision
1. Unless coughing is contraindicated, place a pillow, towel, or folded blanket over surgical incision and hold the item firmly in place. 2. Take 3 slow, deep breaths to stimulate your cough reflex. 3. Inhale through nose, and then exhale through mouth. 4. On 3rd deep breath, cough to clear secretions from lungs while firmly holding the pillow, towel, or folded blanket against incision.
Expansion Breathing:
1 Find a comfortable upright position, with your knees slightly bent. (Bending the knees decreases tension on the abdominal muscles and decreases respiratory resistance and discomfort.) 2 Place your hands on each side of your lower rib cage, just above your waist. 3 Take a deep breath through your nose, using your shoulder muscles to expand your lower rib cage outward during inhalation. 4 Exhale, concentrating first on moving your chest, then on moving your lower ribs inward, while gently squeezing the rib cage and forcing air out of the base of your lungs
Order to return to consciousness after general anesthesia
1. Muscular irritability 2. Restlessness and delirium 3. Recognition of pain 4. Ability to reason and control behavior
Analysis The priority collaborative problems for pts in the immediate postop phase are
1. Potential for decreased gas exchange due to the effects of anesthesia, pain, opioid analgesics, and immobility 2. Potential for infection and delayed healing due to wound , location, decreased mobility, drains and drainage, and tubes 3. Acute pain due to the surgical incision and procedure, and surgical positioning 4. Potential for decreased peristalsis due to surgical manipulation, opioid use, fluid and electrolyte imbalances
Order to return of motor and sensory functioning after local or regional anesthesia
1. Sense of touch 2. Sense of pain 3. Sense of warmth 4. Sense of cold 5. Ability to move
Deep (Diaphragmatic) Breathing: preop respiratory care
1. Sit upright on the edge of the bed or in a chair, being sure that your feet are placed firmly on the floor or a stool. (After surgery, deep breathing is done with the patient in Fowler's position or in semi-Fowler's position). 2. Take a gentle breath through your mouth 3. Breathe out gently and completely 3. Take a deep breath through nose and mouth, and hold this breath to the count of 5 4. Exhale through your nose and mouth
Nclex 9.2 Reduction of risk potential The nurse is caring for a client who is to undergo surgery at 6am today. Which assessment data will the nurse communicate immediately to the surgeon and anesthesia provider? SATA A. BP 130/72 mm Hg B. Serum potassium 3.5 mEq/L C. Diffuse rash on upper torso D. Took 650 mg of aspirin yesterday E. Has not had food or water since 9pm last night
= C, D
A nurse in the preoperative holding area is admitting a woman prior to reduction mammoplasty. What should the nurse include in the care given to this patient? Select all that apply. A) Establishing an IV line B) Verifying the surgical site with the patient C) Taking measures to ensure the patient's comfort D) Applying a grounding device to the patient E) Preparing the medications to be administered in the OR
A, B, C Feedback: In the holding area, the nurse reviews charts, identifies patients, verifies surgical site and marks site per institutional policy, establishes IV lines, administers medications, if prescribed, and takes measures to ensure each patient's comfort. A nurse in the preoperative holding area does not prepare medications to be administered by anyone else. A grounding device is applied in the OR.
Nclex 9.4 The nurse has prepared a client for transport from the medical-surgical unit to surgery. Which client statement will be the nurse respond to as the priority? A. When I eat shrimp, my tongue swells and I have trouble breathing B. I'm feeling more anxious about my surgery than I thought I would be C. I'm not sure what I will do if insurance doesn't cover this expensive hip replacement D. My sister had anesthesia a few months ago and she said she didn't like the way she felt
Ans = A
risk for surgical complications table 9.3
Age; >65 Medications; antihypertensives, tricyclic antidepressants, anticoagulants, NSAIDs Medical history; decreased immunity, diabetes, pulmonary disease, cardiac disease, hemodynamic instability, multisystem disease, coagulation defect or disorder, anemia, dehydration, infection, hypertension, hypotension, any chronic disease Prior surgical experiences; less than optimal emotional reaction, anesthesia reactions or complications, postoperative complications Health History; malnutrition or obesity, drug tobacco, albohol or illicit drug use, altered coping ability family History; malignant hypothermia, cancer, bleeding disorder Type of procedure planned;
TeamSTEPPS
An evidence-based framework to optimize team performance across the health care delivery system. Has 5 key principles. It is based on team structure and four teachable-learnable skills: Communication, Leadership, Situation, Monitoring, and Mutual Support. According to this framework, two attempts should be made to notify a health care provider before proceeding through the chain of command.
Nclex 9.3 Reducing risk potential The nurse is teaching a client about postop leg exercises. What teaching will the nurse include? SATA A. Begin practicing leg exercises prior to surgery B. Repeat leg exercises several times daily for each leg C. Push the ball of the foot into the bed until the calf and thigh muscles contract D. If pain or warmth in the calf is present, discontinue exercises and contact the surgeon E. Point toes of one foot toward bed button, then point toes of the same leg toward face. Switch
Ans - A, C, D, E
Nclex 9.5 The nurse is caring for a client who has been readmitted to the med-surg unit following surgery for a hernia repair completed under general anesthesia. What is the priority nursing assessment? A. Perform thorough auscultation of the lungs B. Assess responses to pinprick stimulation from feet to mid-chest level C. Determine LOC and response to environmental stimuli D. Compare BP findings from preop assessment to the present
Ans = A
Nclex 9.6 In the early postop phase, which assessment finding in a client who had an epidural during surgery requires immediately nursing intervention? A. BP of 142/90 mm Hg B. Headache of 4 on a 1-10 scale C. Gradual return of motor function D. Increase in back pain when coughing
Ans = A
NCLEX 9.1 The surgery for a client scheduled for an 8am procedure is delayed until 11am. What is the appropriateness nursing actions regardless administering of preop prophylactic antibiotics? A. Administer at 8am as originality prescribed B. Adjust the administration time to be given at 10am C. Do not administer as preop prophylactic antibiotics are optional D. Hold the antibiotic until immediately follow surgery ,and then administer
Ans = B
Nclex 9.7 The nurse is caring for a client who reports being fearful of becoming dependent on opioid pain meds after surgery. What is the appropriate nursing response. SATA A. Why do you think you're going to get hooked B. Don't worry, I won't give you any opioid meds C. Have you had concerns with drug dependence in the past D. Tell me what makes you most fearful about taking opioid meds E. There are proper ways of taking opioids so you will not become dependent
Ans = C, D, E
preop medications
Anxiolytics = reduce anxiety Sedatives , hypnotics - promote relaxation Anticholinergic agents = reduce nasal and oral secretions Prevent laryngospasm = Reduce vagal-induced bradycardia = H2 histamine blockers = inhibit gastric secretions Opioids = decrease amount of anesthetic needed for induction and maintenance
Postanesthesia phases (3)
Phase 1 : - Occurs immediately after surgery - in the PACU - If pt has serious complications, phase 1 occurs in = ICU **the length of time the pt remains in phase 1 is based on : health status, surgical procedure, anesthesia type, rate of progression to regain alertness and hemodynamic stability - range from 1 hr to days - ongoing monitoring
Older adults: Changes of aging as surgical risk factors
Decreased: -Cardiac output, peripheral circulation -Vital capacity, blood oxygenation -Blood flow to kidneys, glomerular filtration rate Increased: -Blood pressure -Risk for skin damage, infection -Sensory deficits -Deformities related to osteoporosis/arthritis
Reasons for surgery
Diagnostic - Determines origin and cause of disorder Curative - Resolves health problem by repairing or removing cause Restorative - Improves patient's functional ability Palliative - Relieves symptoms of disease process, but does not cure Cosmetic - Alters/enhances personal appearance
Preop electronic health record review
Ensure all documentation, preoperative procedures, orders are complete Check surgical consent form and others for completeness Inform patient that area will be marked before procedure begins Document allergies, height, and weight Ensure all laboratory and diagnostic test results are in chart and abnormal results noted
Surgical Approach Radical
Extensive surgery beyond the area obviously involved; is directed at finding a root cause Such as : Radical prostatectomy Radical hysterectomy
Urgency of Surgery Emergent surgery examples Requires immediate intervention because of the life-threatening consequences
Gunshot or stab wound Severe bleeding Abdominal aortic aneurysm Compound fracture Appendectomy
Management of dehiscence
If dehiscence occurs, apply a sterile nonadherent (tefla) or saline dressing to the wound and notify the surgeon. +Instruct the patient to bend the knees and to avoid coughing.
NPO before surgery - decreases the risk of aspiration
No clear liquids for 2 hours before surgery no breast milk for 4 hours before surgery No solids, formula or nonhuman milk for 6 hours No fatty, fried, or meat for 8 hours some hospitals keep the patients NPO 8 hours before surgery or after midnight NPO until after surgery Patient's need clarified medications: they will get their cardiac meds and respiratory meds they get their hormones (thyroid)
Patients at risk for VTE
Obese patients Age 40 or older History of cancer Decreased mobility or immobile Spinal cord injury Smoking History of VTE, PE, varicose veins, edema Oral contraceptives History of decreased cardiac output Hip fracture, total hip/knee surgery
Surgical Approach
RIMS Simple, Minimally invasive, radical
These should be reported to reduce potential risk before, during, and after surgery
Report pertinent cardiovascular and respiratory findings: - cp - irregular HR - hypotension or HTN - HR < 60 or > 100 beats/min - SOB, dyspnea, tachypnea - pulse oximetry reading of <94 % - presence of implantable cardiovascular devices such as a pacemaker or implantable cardioverter defibrillator (ICD) Report any s/s of infection, including - fever - purulent sputum - increase WBC - dysuria or cloudy, foul-smelling urine - any red, swollen, draining IV or wound site Report lab data that could contraindicate surgery, including -hypokalemia or hyperkalemia - positive pregnancy test result (or pt report of actual or possible pregnancy) - increased prothrombin time (PT), international normalized ratio (INR), or activated partial thromboplastin time (aPTT) Report other clinical conditions that may need further evaluation before proceeding with the surgical plans , including - rash - vomiting - change in mental status - recent administration of an anticoagulant drug
Rapid , shallow respirations may signal
Shock, cardiac problems, increased metabolic rate, or pain
Surgical Approach MInimally Invasive Surgery (MIS)
Surgery performed in a body cavity or body area through one of more endoscopic; can correct problems, remove organs, take tissue for biopsy, reroute blood vessels, and drainage systems, is a fast-growing and ever-changing type of surgery Eg: Arthroscopy Tubal ligation Hysterectomy Lung lobectomy Coronary artery bypass Cholecystectomy
What the perioperative nurse Not responsible for ?
The perioperative nurse is Not responsible for providing detailed information about the surgical procedure
Prevention of cardiovascular complications
VTE leg exercises mobility
Coughing and splinting
___ and ___ are performed along with deep breathing every 1-2 hours after surgery and help to expel secretions and keep the lungs clear
Indications of anxiety
anger, crying, restlessness, profuse sweating, increased pulse rate, palpitations, sleeplessness, diarrhea, and urinary frequency
autologous transfusion
occurs when a patient donates one's own blood for a transfusion *** done a few weeks before the surgery = autologous = eliminates transfusion reactions and reduces the risk for acquiring bloodborne disease ** special tag is placed on the blood bag when an autologous blood is donated = pt gets matching tag and wears or bring to the surgical area before surgery
Dehiscence
partial or total separation of wound layers
Evisceration
protrusion of viscera through an incision
Urgency of Surgery Urgent surgery examples
surgery that is not an emergency, but must be done within a reasonably short time frame to preserve health Such as : Intestines obstruction Bladder obstruction Kidney or ureteral stones Bone fracture Eye injury Acute cholecysitis
Management of evisceration pg 181 for emergency care
surgical emergency -
Directed blood donation
when family and friends donate blood for the exclusive use of the patient