Chapter 29: Perioperative Nursing
guidelines for pain management
(1) the pain reported by the patient is the determining factor of pain control, (2) pain must be assessed as often as every 2 hours after major surgery, (3) the older patient is at risk for both undertreatment and overtreatment of pain.
Prevent Respiratory Complications
*ICOUGH* •Incentive spirometry •Coughing/deep breathing' •Oral care•Understanding (patient and staff education) •Getting out of bed at least three times daily •Head of bed elevation
Moderate sedation/analgesia
- (conscious sedation/analgesia) - used for short-term, minimally invasive procedures - The patient maintains cardiorespiratory function - Pt can respond to verbal commands - the IV administration of sedatives and analgesics raises the pain threshold and produces an altered mood with some degree of amnesia
Coughing
- Coughing helps *remove retained mucus* from the respiratory tract and usually is taught in conjunction with deep breathing. - Coughing is especially important in patients with an increased risk for respiratory complications. - Because coughing is often painful, teach the patient how to splint the incision (i.e., support the incision with a pillow or folded bath blanket) and to use the period after pain medication has been administered to best advantage. See Guidelines for Nursing Care 29-2 on how to teach the patient how to cough effectively.
what happens to respiration process during surgery?
- DURING surgery, the *cough reflex is suppressed*, mucus accumulates in the tracheobronchial passageways, and the lungs do not ventilate fully. - AFTER surgery, respirations often are less effective as a result of the anesthesia, pain medications, and pain from the incision. - Patients who have *thoracic* or *high abdominal* incisions are especially prone to *shallow breathing* because of incisional pain with deeper respirations. As a result, alveoli do not inflate and may collapse, and secretions are retained, increasing the risk for atelectasis and respiratory infection
Surgeries based on urgency
- Elective surgery - Emergency surgery - Urgent surgery
Deep Breathing
- Place the patient in semi-Fowler's. - Ask the patient to hold their breath for 3-5 seconds. - Exhale through the mouth with pursed lips. - Repeat 3 times. - This exercise should be done every 1-2 hours while the patient is awake. WHY DO IT ? breathing exercises hyperventilate the alveoli and prevent them from collapsing again, improve lung expansion and volume, help to expel anesthetic gases and mucus, and facilitate oxygenation of tissues
Minor
- Primarily elective - outpatient settings / same day surgery - *LOW RISK* •To remove skin lesions •To correct deformities EX: Teeth extraction, removal of warts, skin biopsy, dilation
General, or systemic, anesthesia:
- a combination of both *I.V.* and *inhalation* anesthetics. - the patient is *non arousable*, not even to painful stimuli. they lose the ability to maintain ventilatory function and require *assistance maintaining a patent airway*
Manifestations of atelectasis
- decreased lung sounds over the affected area, - dypsnea, - cyanosis, - crackles, - restlessness, - apprehension
Manifestations of pulmonary embolus
- dyspnea, - chest pain, - cough, - cyanosis, - rapid respiration, - tachycardia, - anxiety
Endocrine diseases:
- especially *diabetes mellitus*, increase the risk for hypoglycemia or acidosis, slow wound healing and present an increased risk for postoperative cardiovascular complications
Manifestations of pneumonia
- fever, - chills, - a cough that produces rusty or purulent sputum, - crackles, and wheezes, - dyspnea, - chest pain
Adverse effects of spinal anesthesia:
- hypotension, - headache, - urine retention
Kidney and Liver diseases:
- influence the patients response to anesthesia, - affect fluid and electrolyte as well as acid-base balance, - alter the metabolism and excretion of drugs - impair would healing
Major
- may be elective/urgent/emergency •To preserve life •To remove or repair a body part •To restore function •To improve or maintain health EX: cholecystectomy, nephrectomy, colostomy, hysterectomy, radical mastectomy *HIGH RISK*
Regional anesthesia:
- occurs when an anesthetic agent is injected near a *nerve* or nerve pathway in or around the operative site. - The patient remains *awake*, but *loses sensation* in a specific region or area of the body
What are manifestations of Thrombophlebitis?
- pain and cramping in the calf or thigh of the involved extremity, - redness and swelling in the affected area, - elevated temperature, - increase in diameter of the involved extremity
Respiratory disorders that place the patient at risk during surgery
- pneumonia, - bronchitis, - asthma, - emphysema, and - COPD, ==== increase the risk for *respiratory depression* from anesthesia as well as *postoperative pneumonia*, *atelectasis*, and alterations in *acid-base balance*
leg exercises
- to increase venous return
Alternative methods of pain control:
- transcutaneous electrical nerve stimulation (TENS), ------------ pressure-controlled pain pumps filled with local anesthetics, - patient controlled analgesia (PCA), - patient-controlled epidural anesthesia
Topical Anesthesia:
- used on mucous membrane : nose. mouth, open wound - sprayed , spread or applied - Cocaine in a 4% to 10%, Lidocaine, and Bupivicaine
TURNING IN BED
-Turning in bed improves *venous return*, *respiratory function*, and *intestinal peristalsis* and *prevents the unrelieved skin pressure* that would occur if the patient were to remain in only one position. - To turn in bed patients should: 1) raise one knee, 2) reach across to grasp the side rail on the side toward which they are turning, 3) roll over while pushing with the bent leg and pulling on the side rail. 4) A small pillow is useful for splinting the incision while turning. - The patient should turn and change positions in bed *every 2 hours* when awake.
Cardiovascular Diseases that place the patient at risk during surgery
-thrombocytopenia, - hemophilia, - recent myocardial infarction or cardiac surgery, - heart failure, and dysrhythmias, ====increase the risk for - hemorrhage and hypovolemic shock, - hypotension, - venous stasis, - thrombophlebitis, - over hydration with IV fluids
Surgeries based on degree of risk
1) Major 2) Minor
3 phases of perioperative phase
1) preoperative phase 2) intraoperative phase 3) postoperative phase
The postoperative phase can be divided into two stages:
1. Immediate care 2. ongoing postoperative care
The three phases of general anesthesia:
1. induction 2. maintenance 3. emergence
Consciousness returns in what order?
1. unconsciousness 2. response to touch and sounds 3. drowsiness 4. awake but not oriented 5. awake and oriented
To decrease the amount of bacteria in the air, standard OR ventilation provides how many air exchanges per hour?
15 air exchanges per hour, at least 3 of which are fresh air
What temperature is the OR kept at?
20-24 degrees Celsius; 68-73 degrees Fahrenheit, and humidity between 30-60%
Nerve Blocks:
A type of Regional anesthesia accomplished by injecting a local anesthetic around a nerve trunk supplying the area of surgery
Spinal anesthesia
A type of Regional anesthesia. Achieved by injecting a local anesthetic into the *subarachnoid space* through a lumbar puncture. It is used for surgery of the lower abdomen, perineum, and legs
Caudal anesthesia:
A type of Regional anesthesia. Is the injection of the local anesthetic into the *epidural space* through the caudal canal in the *sacrum*. May be used for procedures on the lower extremities or perineum
Epidural anesthesia
A type of Regional anesthesia. involves the injection of the anesthetic through the *intervertebral spaces*, usually in the *lumbar region*. It is used for surgeries of the arms, shoulders, thorax, abdomen, pelvis, and legs
Adrenal steroids increase surgical risk by:
Abrupt withdraw may cause cardiovascular collapse in long-term users
How are surgical procedures classified?
According to urgency, risk, and purpose
The nurse is aware that which of the following helps to stimulate T-cell response:
Arginine is necessary for collagen synthesis and deposition, increases wound strength, and stimulates T-cell response.
Immediate Postoperative assessments
Assessed every 10-15 minutes
Atracurium
Atracurium is a nondepolarizing muscle relaxant
Stage One:
Beginning Anesthesia: Unnecessary noises and motions are avoided when anesthesia begins
The Preoperative Phase
Begins when the patient and surgeon mutually decide that surgery is necessary and will take place. It ends when the patient is transferred to the operating room or procedural bed
The Intraoperative Phase
Begins when the patient is transferred to the OR bed, also called a table, until transfer to the postanesthesia care unit (*PACU*) = recovery area
Buddhists may choose not to use:
Bovine (Beef) products
Which of the following medications may increases the hypotensive action of anesthesia?
Chlorpromazine; Thorazine
Based on Urgency:
Elective, urgent, and emergency
Stage II:
Excitement: Pupils dilate, pulse rate is rapid, and respirations may be irregular
The Postoperative Phase
Lasts from admission to the recovery area (*PACU*) to complete recovery from surgery and the last follow-up physician visit
Stage IV:
Medullary depression: is characterized by shallow respirations, a weak, thready pulse, dilated pupils that do not react to light, and cyanosis
How would a patient who has a systemic disease not related to surgery be classified?
P2, P3, or P4
The Postoperative Phase can be divided into:
Phase one, Phase II, and Phase III,
During the preoperative assessment, the nurse learns that the client has been taking prednisone. The nurse realizes that the client is at risk for
Prednisone, a corticosteroid, can result in cardiovascular collapse if suddenly discontinued
Phase one
Providing patient care from a totally anesthetized state to one requiring less acute nursing interventions
Succinylcholine
Succinylcholine is a depolarizing muscle relaxant
Stage III:
Surgical Anesthesia: Respiration's are regular, pulse rate and volume are normal, skin is pink or slightly flushed
What position is used for gynecologic, rectal and urologic procedures?
The lithotomy position
During the first 24 hours after surgery, how often will the nurse evaluate the client's vital signs?
The pulse rate, blood pressure, and respiration rate are recorded at least every 15 minutes for the first hour and every 30 minutes for the next 2 hours. Thereafter, they are measured less frequently if they remain stable. The temperature is monitored every 4 hours for the first 24 hours.
What type of blood clot is most commonly seen in postoperative patients?
Thrombophlebitis from venous stasis is most commonly seen in the legs of postoperative patients
Sudden withdrawal of which of the following may result in seizures?
Tranquilizers
What position is commonly used for minimally invasive surgery of the lower abdomen or pelvis?
Trendelenburg position
Embolus
a blood clot or foreign substance that is dislodged and travels through the blood stream until it lodges in a smaller vessel
Anesthesia
a method and technique of making potentially uncomfortable interventions tolerable and safe
P6 refers to:
a patient who is brain dead and is undergoing surgery as an organ donor
Elective surgery
a procedure that is *preplanned* and based on the patients choice and availability of scheduling for the patient, surgeon, and facility. this is a *non urgent procedure* that does not have to be done immediately EX: cataract extraction, tonsilectomy
The RNFA:
actively assists the surgeon by providing exposure of the operative area, hemostasis (blood clotting), and wound closure
A patient who is malnourished is at a higher risk for:
alterations in fluid and electrolyte balance, delay in wound healing, and wound infection
Hemorrhage
an excessive internal or external blood loss, which may lead to hypovolemic shock
Thrombophlebitis
an inflammation of a vein associated with thrombus formation
Semirestricted Zone:
attire consists of scrub clothes and caps
Induction
begins with administration of the anesthetic agent and continues until the patient is ready for the incision.
Usual presurgical screening tests:
chest x-ray, electrocardiography, complete blood count, electrolyte levels, and urinalysis
time-out:
component of the universal protocol, just prior to beginning a surgical procedure, to verify the patient's identity and the correct surgical site and procedure
Maintenance
continues from the point when patient is ready for the incision until near the completion of the procedure.
The APN:
coordinates care activities, collaborates with physicians and nurses in all phases of perioperative and postanesthesia care, research into care of the surgical patient
Trendelenburg position side effects
decreases diaphragmatic movement and respiratory exchange; blood pools in the upper torso, blood pressure increases; hypotension can result with return to the supine position
what are other related symptoms of shock?
decreasing blood pressure, cyanosis, a cool skin temperature, and a decrease in urine output
Based on purpose:
diagnostic, ablative, palliative, reconstructive, transplantation, constructive
Clinical manifestations of a wound infection include:
fever, tachycardia, an elevated white blood cell count, and increased incisional pain
If the patients screening test shows a hemoglobin less than ____ and a hematocrit of less than _____ blood component should be given preoperatively
hemoglobin <10 and hematocrit <33%
Specific cardiovascular complications include:
hemorrhage, shock, thrombophlebitis, and pulmonary embolus
What is the most common type of shock seen in postoperative patients?
hypovolemic shock, which occurs from a decrease in blood volume
The circulating nurse:
identifies and assesses the patient on admission to the operating room, collaborates in safely positioning the patient on the operating bed, assists with monitoring the patient during surgery, provides additional supplies, maintains environmental safety, and counts the number of instruments
Atelectasis
incomplete expansion or collapse of alveoli with retained mucus, involving a portion of lung and resulting in poor gas exchange
Why are infants at greater risk from surgery?
infants have a *lower total blood volume*, placing them at a risk for *dehydration*. The infant also has *difficulty maintaining stable body temperature* during surgery. Their *lower glomerular filtration rate* and *creatinine clearance* can lead to a slower metabolism of drugs.
Pneumonia
inflammation of the alveoli as the result of an infectious process or the presence of foreign material
The scrub nurse:
is a member of the sterile team who maintains surgical asepsis while draping and handling instruments and supplies
Optional surgery
is not critical to survival or function
Pre-admission testing:
is often conducted several days before surgery as part of preoperative laboratory screening and teaching
What is a wound assessment indicative of hemorrhage and hypovolemic shock?
large amounts of bright red drainage, combined with other abnormal physical status assessments such as: restlessness, pallor, cold moist skin, decreasing blood pressure, and increasing pulse and respiratory rates
Based on degree of risk:
major which may be elective urgent, or emergency, and minor which is primarily minor
Diuretics increase surgical risk by:
may cause electrolyte imbalances, with resulting respiratory depression from anesthesia
Tranquilizers increase surgical risk by:
may increase the hypotensive effect of anesthetic agents
Anticoagulants increase surgical risk by:
may precipitate hemorrhage
Oral antidiabetic medications such as metformin hydrochloride increase surgical risk by:
may react with radiologic (x-ray) iodinized contrast dyes, and cause acute renal failure
Emergency surgery
must be done *immediately* to preserve life, a body part, or function EX: intestinal obstruction, tracheotomy, repair of trauma
Urgent surgery
must be done within a *reasonably short time frame* to preserve health, but is not an emergency. Usually done within 24-30 hours EX: removal of malignant tumor,amputation
perioperative phase
periods of surgery progression
What is shock position?
placing the client flat with the legs elevated 30-45 degrees
What complications can hypothermia cause?
poor wound healing, hemodynamic stress, cardiac disturbances, coagulopathy, delayed emergence from anesthesia, shivering and its associated discomfort
Muslims and those of Jewish faith cannot use:
porcine-based products; heparin. porcine or bovine
Phase II
preparing the patient for self or family care or for care in a phase III extended care environment
Brachial Plexus Block:
produces anesthesia of the arm
Paravertebral Anesthesia:
produces anesthesia of the nerves supplying the chest, abdominal wall, and extremities
Transsacral (caudal) Block:
produces anesthesia of the perineum and, occasionally the lower abdomen
Laminar Airflow Units
provide 400-500 air exchanges per hour. Generally used for joint replacement or organ transplant surgery
Phase III
providing ongoing care for patients requiring extended observation or intervention after transfer for discharge from phase one or II
What are specific postoperative respiratory complications?
pulmonary embolus, pneumonia, and atelectasis
Patients with a large habitual intake of alcohol:
require larger doses of anesthetic agents and postoperative analgesics, increasing the risk for drug-related complications
Patients who smoke are at higher risk for:
respiratory complications, hypoxia, postoperative pneumonia
What is the most common PACU emergency?
respiratory obstruction
What assessments are made in the PACU?
respiratory status, cardiovascular status, central nervous system status, fluid status, wound status, and general condition
A patient who is obese is at a higher risk for:
respiratory, cardiovascular, positional injury, DVT, and gastrointestinal problems
Common manifestations of hemorrhage include:
restlessness, anxiety, frank bleeding hypotension; cold, clammy skin; a weak, thready, and rapid pulse; cool, mottled extremities; deep, rapid respirations, decreased urine output; thirst; apprehension : anxiety
Risk of lithotomy position?
risk for thrombophlebitis
What position would you place a client in who has pneumonia?
semi-Fowler's or Fowler's position
In what position would you place a client in who has presence of atelectasis?
semi-Fowler's position
What position would you place a patient in who has an embolus?
semi-Fowler's position instructing the patient to avoid Valsalva's maneuver
Postanesthesia Rough handling can cause?
severe hypotension or potentially lethal cardiac or respiratory arrest
How is postoperative fluid status assessed?
skin turgor, vital signs, urine output, wound drainage, IV fluid intake
Emergence
starts as the patient begins to awaken from the altered state induced by the anesthesia and usually ends when the patient is ready to leave the operating room
Unrestricted Zone:
street clothes are allowed
Anticholinergics
such as atropine and glycopyrrolate (Robinul), to decrease pulmonary and oral secretions and to prevent laryngospasm
Histamine-2 receptor blockers,
such as cimetidine (Tagamet) and ranitidine (Zantac), to decrease gastric acidity and volume
Sedatives
such as diazepam (Valium), midazolam (Versed), or lorazepam (Ativan) to alleviate anxiety and decrease recall of events related to surgery
Neuroleptanalgesic agents
such as fentanyl citrate-droperidol (Innovar), to cause a general state of calmness and sleepiness
Narcotic analgesics
such as morphine, to facilitate patient sedation and relaxation to decrease the amount of anesthetic agent needed
What is an EARLY symptom of shock?
tachycardia
How is postoperative cardiovascular function assessed?
taking vital signs, monitoring electrocardiogram rate and rhythm, and observing skin color and condition
Shock
the body's reaction to acute circulatory failure as the result of an alteration in circulatory control or a loss of intravascular fluid
Local Anesthesia
the injection of an anesthetic agent such as Lidocaine, Bupivicaine, or tetracaine to a specific area of the body
Palliative
to relieve or reduce intensity of an illness; is not curative
Ablative
to remove a diseased body part Examples: appendectomy, subtotal thyroidectomy, colon resection, and amputation
Constructive
to restore function in congenital anomalies. Examples: cleft palate repair, closure of atrial-septal defect
Reconstructive
to restore function to traumatized or malfunctioning tissue. ; improve self -perception Examples: scar revision, plastic surgery, skin graft, internal fixation of a fracture
Moderate sedation/analgesia
used for short term and minimally invasive procedures. The patient retains the ability to keep their airway open and can respond appropriately
Assessments to be made in the PACU:
vital signs are to be monitored every 15 minuets until stable, changing every 1-2 hours for the first 24 hours, and every 4 hours thereafter
antibiotics in the mycin group increase surgical risk by:
when combined with certain muscle relaxants used during surgery, may cause respiratory paralysis
When can a patient be discharged?
when they are no longer drowsy or dizzy, have stable vital signs, and has voided
Restricted Zone:
where scrub clothes, shoe covers, caps and masks are worn
The intra-operative phase of surgery begins:
with the admission of the patient to the surgical area and lasts until the patient is transferred to the PACU
Informed Consent Information
• Description of procedure and alternative therapies • Underlying disease process and its natural course • Name and qualifications of person performing procedure • Explanation of risks and how often they occur • Explanation that the patient has the right to refuse treatment or withdraw consent • Explanation of expected outcome, recovery, rehabilitation plan, and course of treatment
Patient Risk Factors and Strengths
• Developmental level • Medical and surgical history • Medication history • Nutritional status • Use of alcohol, illicit drugs, or nicotine • Activities of daily living and occupation • Coping patterns and support systems • Sociocultural needs
Nurse's Role in Pre-surgical Testing
• Ensure that tests are explained to the patient. • Ensure that appropriate specimens are collected. • Ensure that results are recorded in patient records before surgery. • Ensure that abnormal results are reported.
Nursing Interventions to Meet Psychological Needs of Surgical Patients
• Establish therapeutic relationship and allow patient to verbalize fears and concerns. • Use active listening skills to identify anxiety and fear. • Use touch to demonstrate genuine empathy and caring. • Be prepared to respond to common patient questions about surgery.
Types of Anesthesia
• General • Moderate sedation/analgesia (conscious sedation/analgesia): used for short-term, minimally invasive procedures • Regional: anesthetic agent injected near a nerve or nerve pathway or around operative site • Topical and local anesthesia: used on mucous membranes, open skin, wounds, burns
Cardiovascular Complications
• Hemorrhage • Shock • Thrombophlebitis • Pulmonary embolus
Nursing Interventions for Surgical Patients
• Hygiene and skin preparation • Elimination • Nutrition and fluids • Rest and sleep • Preparation and safety the day of surgery
Advance Directives
• Living wills • Durable power of attorney for health care
States of Anesthesia
• Loss of consciousness • Analgesia • Relaxed skeletal muscles • Depressed reflexes
Interventions to Prevent Respiratory Complications
• Monitoring vital signs • Implementing deep breathing • Coughing • Incentive spirometry • Turning in bed every 2 hours • Ambulating • Maintaining hydration • Avoiding positioning that decreases ventilation • Monitoring responses to narcotic analgesics
Types of Regional Anesthesia
• Nerve blocks • Spinal anesthesia • Caudal anesthesia • Epidural anesthesia
TJC Protocol to Prevent Wrong Site, Wrong Procedure, and Wrong Person Surgery
• Preoperative patient identification verification process • Marking the operative site • Final verification just prior to beginning the procedure, referred to as the *time-out*
Outcomes for the Surgical Patient
• Receive respectful and appropriate care • Be free from injury and adverse effects • Be free from infection and DVT • Maintain fluid and electrolyte balance; skin integrity, normal temperature • Have pain managed • Demonstrate understanding of physiologic and psychological responses to surgery • Participate in rehabilitation process
Outpatient/Same-Day Surgery
• Reduces length of hospital stay and cuts costs • Reduces stress for the patient • May require additional teaching and home care services for certain patients - Older patients, chronically ill patients, patients with no support system
Postoperative Assessments and Interventions (Every 10 to 15 Minutes)
• Respiratory status (airway, pulse oximetry) • Cardiovascular status (blood pressure) • Temperature • Central nervous system status (level of alertness, movement, shivering) • Fluid status • Wound status • Gastrointestinal status (nausea and vomiting) • General condition
Typical Preoperative Medications
• Sedatives • Anticholinergics • Narcotic analgesics • Neuroleptanalgesic agents • Histamine receptor antihistamines
Preparing the Patient Through Teaching
• Surgical events and sensations • Pain management • Physical activities - Deep breathing - Coughing - Incentive spirometry - Leg exercises - Turning in bed
Return of Consciousness
• Unconscious • Response to touch and sounds • Drowsiness • Awake but not oriented • Awake and oriented
PROVIDING PREOPERATIVE PATIENT CARE: HOSPITALIZED PATIENT (DAY OF SURGERY)
•Check that preoperative consent forms are signed and dated, witnessed, and correct; that advance directives are in the medical record (as applicable); and that the patient's chart is in order. •Gather the needed equipment and supplies. •Perform hand hygiene. •*Check vital signs*. Notify physician of any pertinent changes (i.e., rise or drop in blood pressure, elevated temperature, cough, symptoms of infection). •Provide hygiene and oral care. Assess for loose teeth. Verify adherence to food and fluid restrictions before surgery. •Instruct the patient to remove all personal clothing, including underwear, and put on a hospital gown. •Ask patient to remove cosmetics, jewelry including body piercing, nail polish, and prostheses (e.g., contact lenses, false eyelashes, dentures). •Have patient *empty bladder* before surgery. •Attend to any special preoperative orders, such as starting an IV line. •Complete preoperative checklist and record of patient's preoperative preparation. •*Administer preoperative medication* as prescribed by physician/anesthesia provider. •Raise side rails of bed; place bed in lowest position. Instruct patient to remain in bed or on stretcher. If necessary, a safety belt may be used. •Help move the patient from the bed to the transport stretcher if necessary. Reconfirm patient identification and ensure that all preoperative events and measures are documented. •Tell the family of the patient where the patient will be taken after surgery and the location of the waiting area where the surgeon will come to explain the outcome of the surgery. •After the patient leaves for the OR, prepare the room and make a postoperative bed for the patient. Anticipate any necessary equipment based on the type of surgery and the patient's history.
EFFECTIVE COUGHING.
•Place the patient in a semi-Fowler's position, leaning forward. •Provide a pillow or folded bath blanket to use in splinting the incision. •Ask the patient to: --•Inhale and exhale deeply and slowly through the nose three times. --•Take a deep breath and hold it for 3 seconds. --•"Hack" out for three short breaths. --•With mouth open, take a quick breath. --•Cough deeply once or twice. --•Take another deep breath. --•Repeat the exercise every 2 hours while awake