Perioperative Nursing Care
Perioperative Nursing Care
Objectives
List and discuss common purposes of surgery. List the components of preoperative assessment and discuss the purposes and nursing responsibilities. List the components of preoperative patient preparation and discuss the purposes and nursing responsibilities. List and discuss the potential complications of the postoperative period and the preventative measures. Discuss nursing responsibilities related to the postoperative care of patients.
Common Terms
Perioperative Nursing: Includes the preoperative (before), intraoperative (during) and postoperative (after) periods. Preoperative period: This is an important time to address issues that may come up during surgery (Screening) o i.e. assess for bleeding problems, don't want to find out that someone has a bleeding problem as they exsanguinate on the operating table Also can teach patients and family about what to expect before, during and after a procedure o in an emergency, we can prepare the family if the patient isn't alert
Types of Surgeries
1. Diagnostic 2. Therapeutic 3. Palliative 4. Preventive 5. Cosmetic
Types of Surgeries
Diagnostic: Determination of the presence and or extent of the pathology i.e. lymph node bx, bronchoscopy, exploratory laparatomy Therapeutic: Elimination or repair of the pathology Removal of the appendix when it's inflammed, removal of a localized cancer
Types of Surgeries
Palliative: Alleviation of symptoms without curing the underlying disease Rhizotomy (cutting of a nerve root) to decrease pain, colostomy placement to bypass an obstructing colon tumor Preventative: Surgery to remove tissue that has the potential to become pathologic (may not already express a pathologic problem) Total Colectomy in patients with FAP
Types of Surgeries
Cosmetic: The surgery is preformed for aesthetic reasons Repair of scars from burns or injuries, minor cleft palate repairs, face lifts, breast augmentation
Emergency: arises unexpectedly can also occur in a wide variety of settings o ER o OR o Battlefield/Trauma scene Needed within minutes to hours Urgent: delay could be detrimental usually within 24-48 hours
Preoperative education of what to expect in clear, common english can alleviate some fear and anxiety Remember the role of HOPE for our patients, it is often the most common coping strategy
Operative Consent
This is part of the legal preparation for surgery.
Informed consent: an active, shared decision making process between the provider and recipient of care. Has 3 components to make it valid: 1. Adequate Disclosure: of the diagnosis, nature and purpose of the proposed treatment, probability of successful outcome, risks and consequences of moving forward with treatment or alternatives, the prognosis if treatment is not instituted, and if treatment is deviating from standard for their condition. 2. Understanding and Comprehension of above: this has to be assessed before sedating meds can be given (minors can't give consent, severely mentally ill or severely developmentally challenged).
Operative Consent
Informed Consent (cont): 3. Voluntary Consent: Can't be coerced into going through with a procedure. This consent can be revoked at any point leading up to a surgical procedure. Who can give consent? the patient next of kin (in order of kinship): Spouse, Adult Child, Parent, Sibling o Can be designated with a durable power of attorney in case of medical incapacitation
Preoperative Checklist
Preoperative Medications
Benzodiazepines/Barbituates: used for their sedative and amnesic properties Anticholinergics: reduce secretions, and can reduce cramping Opioids: decrease need for intraoperative analgesics and decrease pain Antiemetics: decrease N/V Antibiotics: to prevent infective endocarditis, or where wound contamination is a risk (GI surgery) or where wound infection would cause significant postoperative morbidity o usually given IV Eyedrops: especially with eye surgery (lasik, cataract surgery)
Preoperative Medications
Nursing Roles
Circulating Nurse: Deal with the management of unsterile activities in the operating area Document the the nursing care of the patient o assessments o interventions movement of unsterile items out of the surgical suite o labeling and transporting specimens Scrub Nurse: Is gowned and gloved and able to handle and pass sterile items into the sterile surgical field "Boss" of the sterile field Assists with the actual procedure to varying degrees
Types of Anesthesia
General: Loss of sensation with the loss of consciousness, skeletal muscle relaxation, possible impaired ventilatory and cardiovascular function and elimination of the somatic, autonomic, and endocrine responses, including coughing, gagging, vomiting, and sympathetic nervous system responses. given IV, inhaled, or rectally Technique of choice when: 1.surgical procedures require sig. skeletal muscle relaxation, last for a long time, require awkward positioning or control of respirations 2.patient are extremely anxious 3.refuse or have contraindications for local anesthesia 4.are uncooperative (head injury, intoxication, youth, emotional status, or cannot remain immobile)
Endotracheal Intubation
This is a tube placed into the trachea once IV induction of anesthesia occurs Allows for control of ventilation and airway protection (specifically from aspiration) Complications: o Sore throat/hoarseness o injury to the teeth o failure to intubate o laryngospasm, laryngeal edema Once the tube is placed, an ambu bag is attached and air is instilled, the chest should rise and fall with the instillation of air, and you should be able to hear breath sounds
Types of Anesthesia
Regional: This is the injection of a local anesthetic in or around a specific nerve or group of nerves Nerve blocks: usually done for the palliation of pain o celiac plexus block o brachial plexus block Spinal/Epidural Anesthetic: injection of a local anesthetic into either the subarachnoid space and CSF (spinal) or epidural space (epidural) o Spinal blocks: cause autonomic, sensory and motor blockade, used for lower abdomen, perineal, groin, or lower extremity can cause hypotension and vasodilation, also spinal headaches o Epidural blocks: anesthetic is given to the epidural space lower incidence of headache
Types of Anesthesia
Local Anesthesia: Usually a topical or injectable agent that provides sensory blockade to a certain area Topical: lidocaine spray at the dentist, EMLA Cream for dermatologic procedures Injectables: Subcutaneous lidocaine or nerve blocks used at the dentist
Patient Positioning
Critical part of every procedure and usually occurs once the anesthesia has been administered. Needs to allow for accessibility of the surgical site, administration of anesthesia, and maintenance of the airway. Must take care to: 1.provide correct skeletal alignment 2.prevent undue pressure on nerves, skin over bony prominences, and eyes 3.provide for adequate thoracic excursion 4.prevent occlusion of arteries and veins 5.provide some modesty 6.recognize and accommodate for previously assessed skeletal deformities
Patient Positioning
Greatest care must be taken to prevent injury, because: anesthesia has blocked the nerve impulses o the patient can't complain that they have pain or discomfort o can cause: muscle strain joint damage pressure ulcers nerve damage Need to also pay attention to the pooling of blood due to vasodilation, can cause central hypotension
Patient Positioning
1. Supine 2. Prone 3. Trendelenberg 4. Lateral 5. Kidney 6. Lithotomy 7. Jackknife 8. Sitting
Postoperative Hyperthermia: elevated temperatures: 38C or above 24-48 hours post surgery results from inflammatory medications/cytokines that are released in the post operative period to enhance healing
f. Drainage tubes: are they free of kinks and draining properly, check if the tubes need to be attached to suction, check to ensure it is the proper amount of suction, assess type and amount of drainage and know when to call the MD.
h. Safety: Side rails up, instruct the patient not to get out of bed without help, ensure the call light and phone are within reach, secure all tubes and lines properly to prevent dislodgement and injury As the nurse, make sure to dangle the patient for 1-2 minutes the first time the patient gets up out of bed.
i. Proper positioning and comfort j. Equipment
9. Return of Normal Urinary Function: assess for bladder pain and distention (palpation and percussion), assess urinary output, Notify MD if no urine output 6-8 hours post surgery, If patient continues on bed rest, assist the patient into the normal voiding position as possible, provide for adequate privacy (as much as possible)