Chapter 18-20: Perioperative Nursing Care PDF

Preview

Summary

CHAPTER 18-20:Perioperative NursingI. PERIOPERATIVE OVERVIEWINTRODUCTION● Perioperative nursing is a term used to describe the nursing care provided in the total surgical experience of the patient: preoperative, intraoperative, and postoperative. ● Preoperative phase from the time the decision is ma...

Description

CHAPTER 18-20: Perioperative Nursing I. PERIOPERATIVE OVERVIEW INTRODUCTION ●

● ● ●

Perioperative nursing is a term used to describe the nursing care provided in the total surgical experience of the patient: preoperative, intraoperative, and postoperative. Preoperative phase from the time the decision is made for surgical intervention to the transfer of the patient to the operating room Intraoperative phase from the time the patient is received in the operating room until admitted to the postanesthesia care unit (PACU). Postoperative phase from the time of admission to the PACU to the follow-up evaluation

TYPES OF SURGERY ● ●

● ● ●

Optional. Surgery is scheduled completely at the preference of the patient (eg, cosmetic surgery). Elective. The approximate time for surgery is at the convenience of the patient; failure to have surgery is not catastrophic (eg, a superficial cyst). Required. The condition requires surgery within a few weeks (eg, eye cataract). Urgent. The surgical problem requires attention within 24 to 48 hours (eg, cancer). Emergency. The situation requires immediate surgical attention without delay (eg, intestinal obstruction).

Common abdominal incisions are pictured in Figure 7-1.

AMBULATORY SURGERY Ambulatory surgery (same-day surgery, outpatient surgery) is a common occurrence for certain types of procedures. The office nurse is in a key position to assess patient status; plan perioperative experience; and monitor, instruct, and evaluate the patient. ● ADVANTAGES ○ Reduced cost to the patient, hospital, and insuring and governmental agencies ○ Reduced psychological stress to the patient ○ Less incidence of hospital-acquired infection ○ Less time lost from work by the patient; minimal disruption of the patient's activities and family life

●

DISADVANTAGES ○ Less time to assess the patient and perform preoperative teaching ○ Less time to establish rapport between the patient and health care personnel ○ Less opportunity to assess for late postoperative complications. This responsibility is primarily with the patient, although telephone and home care follow-up is possible. ● CRITERIA FOR PATIENT SELECTION ○ Surgery of short duration (varies by procedure and institution) ○ Non Infected conditions ○ Type of operation in which postoperative complications are predictably low ○ Age usually not a factor, although too risky in a premature neonate ○ Examples of commonly performed procedures: ■ Ear-nose-throat (tonsillectomy, adenoidectomy) ■ Gynecology (diagnostic laparoscopy, tubal ligation, dilatation and curettage) ■ Orthopedics (arthroscopy, fracture or tendon repair) ■ Oral surgery (wisdom teeth extraction, dental restorations) ■ Urology (circumcision, cystoscopy, vasectomy) ■ Ophthalmology (cataract) ■ Plastic surgery (mammary implants, reduction mammoplasty, liposuction, blepharoplasty, face lift) ■ General surgery (laparoscopic hernia repair, laparoscopic cholecystectomy, biopsy, cyst removal) ● AMBULATORY SURGERY SETTINGS Ambulatory surgery is performed in a variety of settings. A high percentage of outpatient surgery occurs in traditional hospital operating rooms in hospital integrated facilities. Other ambulatory surgery settings may be hospital affiliated or independently owned and operated. Some types of outpatient surgeries can be performed safely in the health care provider's office. Initial assessment: ○ Develop a nursing history for the outpatient; this may be initiated in the health care provider's office.

○

Ensure availability of a signed and witnessed informed consent that includes correct surgical procedure and site. ○ Explain any additional laboratory studies needed and state why. ○ Determine the following during initial assessment of the patient's physical and psychological status: ■ Calm or agitated? ■ Overweight? ■ Disabilities or limitations? ■ Allergies (be sure to include medication, food, and latex allergies)? ■ Medications being taken (also include herbal medications because certain herbs, such as St. John's wort [a mild antidepressant] and feverfew, can affect clotting)? ■ Condition of teeth (dentures, caps, crowns)? ■ Blood pressure problems? ■ Major illnesses? ■ Other surgeries? ■ Seizures? ■ Severe headaches? ■ Smoker? ■ Cardiac or respiratory problems? ○ Begin the health education regimen. Instructions to the patient: ■ Notify the health care provider and surgical unit immediately if you get a cold, have a fever, or have any illness before the date of surgery. ■ Arrive at the specified time. ■ Do not ingest food or fluid before surgery according to institution protocol. Less strict guidelines for fasting have been advocated, but are controversial. ■ Do not wear makeup or nail polish. ■ Wear comfortable, loose clothing and low-heeled shoes. ■ Leave valuables or jewelry at home. ■ Brush your teeth in morning and rinse, but do not swallow any liquid. ■ Shower the night before or day of the surgery. ■ Follow health care provider's instructions for taking medications.

■

Have a responsible adult accompany you and drive you home and have someone stay with you for 24 hours after the surgery.

institution protocol. Nothing by mouth after midnight may not be necessary for surgeries scheduled later in the morning or afternoon.

PREOPERATIVE PREPARATION PATIENT EDUCATION GUIDELINES Outpatient Postanesthesia and Postsurgery Instructions and Information ● Although you will be awake and alert in the Recovery Room, small amounts of anesthetic will remain in your body for at least 24 hours and you may feel tired and sleepy for the remainder of the day. Once you are home, take it easy and rest as much as possible. It is advisable to have someone with you at home for the remainder of the day. ● Eat lightly for the first 12 to 24 hours, then resume a well-balanced, normal diet. Drink plenty of fluids. Alcoholic beverages are to be avoided for 24 hours after your anesthesia or intravenous sedation. ● Nausea or vomiting may occur in the first 24 hours. Lie down on your side and breathe deeply. Prolonged nausea, vomiting, or pain should be reported to your surgeon. ● Medications, unless prescribed by your physician, should be avoided for 24 hours. Check with your surgeon or anesthesiologist for specific instructions if you have been taking a daily medication. ● Your surgeon will discuss your post surgery instructions with you and prescribe medication for you as indicated. You will also receive additional instructions specific to your surgical procedure before leaving the hospital. ● Your family will be waiting for you in the hospital's waiting room area near the Outpatient Surgery Department. Your surgeon will speak to them in this area before your discharge. ● Do not operate a motor vehicle or any mechanical or electrical equipment for 24 hours after your anesthesia. ● Do not make any important decisions or sign legal documents for 24 hours after your anesthesia. NURSING ALERT Prolonged fasting before surgery may result in undue thirst, hunger, irritability, headache; and even dehydration, hypovolemia(decreased intravascular volume), and hypoglycemia. Make sure that patients understand preoperative fasting instructions per

1. Administer pre procedure medication; check vital signs. 2. Escort the patient to surgery after the patient has urinated. 3. Review the patient's chart for witnessed and informed consent, laterality (if applicable), lab work, and history and physical. 4. Verify the correct person, correct site, and correct procedure.

POSTOPERATIVE CARE 1. Check vital signs. 2. Administer oxygen if necessary; check temperature. 3. Change the patient's position and progress activity, head of bed elevated, dangling, ambulating. Watch for dizziness or nausea. 4. Ascertain, using the following criteria that the patient has recovered adequately to be discharged: a. Vital signs stable for at least 1 hour b. Stands without dizziness and nausea; begins to walk c. Comfortable and free of excessive pain or bleeding d. Able to drink fluids and void e. Oriented as to time, place, and person f. No evidence of respiratory depression (2 hours after extubation) g. Has the services of a responsible adult who can escort the patient home and remain with patient h. Understands postoperative instructions and takes an instruction sheet home (see Patient Education Guidelines)

INFORMED CONSENT (OPERATIVE PERMIT) An informed consent (operative permit) is the process of informing the patient abouT the surgical procedure; that is, risks and possible complications of surgery and anesthesia. Consent is obtained by the surgeon. This is a legal requirement. Hospitals usually have a standard operative permit form approved by the hospital's legal department. ● Purposes ○ To ensure that the patient understands the nature of the treatment, including potential complications

○

●

●

●

To indicate that the patient's decision was made without pressure ○ To protect the patient against unauthorized procedures, and to ensure that the procedure is performed on the correct body part ○ To protect the surgeon and hospital against legal action by a patient who claims that an unauthorized procedure was performed Adolescent Patient and Informed Consent ○ An emancipated minor is usually recognized as one who is not subject to parental control: ■ Married minor ■ Those in military service ■ College student under age 18 but living away from home ■ Minor who has a child ○ Most states have statutes regarding treatment of minors. ○ Standards for informed consent are the same as for adults. Procedures Requiring a Permit ○ Surgical procedures whether major or minor. ○ Entrance into a body cavity, such as colonoscopy, paracentesis, bronchoscopy, cystoscopy, or lumbar puncture. ○ Radiologic procedures, particularly if a contrast material is required (such as myelogram, magnetic resonance imaging with contrast, angiography). ○ All types of procedures requiring any type of anesthesia. Obtaining Informed Consent ○ Before signing an informed consent, the patient should: ■ Be told in clear and simple terms by the surgeon what is to be done. The anesthesia care provider will explain the anesthesia plan and possible risks and complications. ■ Have a general idea of what to expect in the early and late postoperative periods. ■ Have a general idea of the time frame involved from surgery to recovery. ■ Have an opportunity to ask any questions. ■ Sign a separate form for each procedure or operation. ○ Written permission is required by law.

○

○ ○ ○

○ ○

Signature is obtained with the patient's complete understanding of what is to occur; it is obtained before the patient receives sedation and is secured without pressure or duress. A witness to the patient's signature is a required nurse, health care provider, or other authorized person. In an emergency, witnessing permission by way of telephone or telegram is acceptable. For a minor (or a patient who is unconscious or irresponsible), permission is required from a responsible family member parent, legal guardian, or court appointed guardian. For a married emancipated minor, permission from the spouse is acceptable. If the patient is unable to write, an X is acceptable if there is a witness to his mark.

SURGICAL RISK FACTORS AND PREVENTIVE STRATEGIES Obesity Danger 1. Increases the difficulty involved in technical aspects of performing surgery (eg, sutures are difficult to tie because of fatty secretions); wound dehiscence is greater 2. Increases the likelihood of infection because of compromised tissue perfusion 3. Increases the potential for postoperative pneumonia and other pulmonary complications because obese patients chronically hypoventilate 4. Increases demands on the heart, leading to cardiovascular compromise 5. Increases the possibility of renal, biliary, hepatic, and endocrine disorders 6. Decreases the ability to conserve heat due to radiant heat loss 7. Alters the response to many drugs and anesthetics 8. Decreases the likelihood of early ambulation THERAPEUTIC APPROACH ● Encourage weight reduction if time permits. ● Anticipate postoperative obesity-related complications.

● ● ●

● ● ●

Be extremely vigilant for respiratory complications. Carefully splint abdominal incisions when moving or coughing. Be aware that some drugs should be dosed according to ideal body weight versus actual weight (owing to fat content), or an overdose may occur (digoxin [Lanoxin], lidocaine [Xylocaine], aminoglycosides, and theophylline [Theo-Dur]). Avoid intramuscular injections in morbidly obese individuals ([I.V. or subcutaneous routes preferred). Never attempt to move an impaired patient without assistance or without using proper body mechanics. Obtain a dietary consultation early in the patient's postoperative course.

Poor Nutrition Danger 1. Preoperative malnutrition (especially protein and calorie deficits and a negative nitrogen balance) greatly impairs wound healing. 2. Increases the risk of infection and shock. THERAPEUTIC APPROACH ● Any recent (within 4 to 6 weeks) weight loss of 10% of the patient's normal body weight should alert the health care staff to poor nutritional status. ● Attempt to improve nutritional status before and after surgery. Unless contraindicated, provide a diet high in proteins, calories, and vitamins (especially vitamins C and A); this may require enteral and parenteral feeding. Reinforce that the postoperative period is not the appropriate time to diet. ● Recommend repair of dental caries and proper mouth hygiene to prevent respiratory tract infection.

circulation). Watch for the fluid shift to reverse (from tissue to circulation) around the third postoperative day. Patients with heart disease may develop failure due to the excess fluid load. THERAPEUTIC APPROACH ● Assess the patient's fluid and electrolyte status. ● Rehydrate the patient parenterally and orally as prescribed. ● Monitor for evidence of electrolyte imbalance, especially Na+, K+, Mg++, Ca++. ● Be aware of expected drainage amounts and composition; report excess and abnormalities. ● Monitor the patient's intake and output; be sure to include all body fluid losses.

Aging Danger 1. Potential for injury is greater in older people. 2. Be aware that the cumulative effect of medications is greater in the older person. 3. Note that medications such as morphine and barbiturates in the usual dosages may cause confusion, disorientation, and respiratory depression. THERAPEUTIC APPROACH ● Consider using lesser doses for desired effect. ● Anticipate problems from chronic disorders such as anemia, obesity, diabetes, hypoproteinemia. ● Adjust nutritional intake to conform to higher protein and vitamin needs. ● When possible, cater to set patterns in older patients, such as sleeping and eating.

Fluid and Electrolyte Imbalance Danger 1. Dehydration and electrolyte imbalances can have adverse effects in terms of general anesthesia and the anticipated volume losses associated with surgery, causing shock and cardiac dysrhythmias. NURSING ALERT Patients undergoing major abdominal operations (such as colectomies and aortic repairs) often experience a massive fluid shift into tissues around the operative site in the form of edema (as much as 1 L or more may be lost from

Presence of Cardiovascular Disease Danger 1. Cardiovascular disease may compound the stress of anesthesia and the operative procedure. 2. Impaired oxygenation, cardiac rhythm, cardiac output, and circulation may result. 3. Cardiac decompensation, sudden arrhythmia, thromboembolism, acute myocardial infarction, or cardiac arrest may occur.

THERAPEUTIC APPROACH ● Frequently assess heart rate and blood pressure, and hemodynamic status and cardiac rhythm if indicated. ● Avoid fluid overload (oral, parenteral, blood products) because of possible myocardial infarction, angina, congestive failure, and pulmonary edema. ● Prevent prolonged immobilization, which results in venous stasis. Monitor for potential deep vein thrombosis (DVT) or pulmonary embolism. ● Encourage position changes but avoid sudden exertion. ● Use antiembolism stockings along with sequential compression devices intraoperatively and postoperatively. ● Note evidence of hypoxia and initiate therapy.

Presence of Diabetes Mellitus Danger 1. Hypoglycemia may result from nothing by mouth status and anesthesia. 2. Hyperglycemia and ketoacidosis may be potentiated by increased catecholamines and glucocorticoids due to surgical stress. 3. Chronic hyperglycemia results in poor wound healing and susceptibility to infection. THERAPEUTIC APPROACH ● Recognize the signs and symptoms of ketoacidosis and hypoglycemia, which can threaten an otherwise uneventful surgical experience. ● Monitor blood glucose and be prepared to administer insulin as directed, or treat hypoglycemia. ● Reassure the diabetic patient that when the disease is controlled, the surgical risk is no greater than it is for the nondiabetic person. DRUG ALERT Most diabetic medication should be continued right up until surgery despite nothing by mouth status; however, metformin (Glucophage) should be suspended due to the risk of lactic acidosis when food and fluids are stopped

Presence of Alcoholism Danger 1. The additional problem of malnutrition may be present in the presurgical patient with alcoholism. The patient may also have an increased tolerance to anesthetics. THERAPEUTIC APPROACH ● Be prepared for rapid sequence induction to lessen the chance of vomiting and aspiration. ● Note that the risk of surgery is greater for the person who has chronic alcoholism. ● Anticipate the acute withdrawal syndrome within 72 hours of the last alcoholic drink.

Presence Pulmonary and Upper Respiratory Disease Danger 1. Chronic pulmonary illness may contribute to hypoventilation, leading to pneumonia and atelectasis. Surgery may be contraindicated in the patient who has an upper respiratory infection because of the possible advance of infection to pneumonia and sepsis. THERAPEUTIC APPROACH ● Patients with chronic pulmonary problems such as emphysema or bronchiectasis should be treated for several days preoperatively with bronchodilators, aerosol medications, and conscientious mouth care, along with a reduction in weight and smoking, and methods to control secretions. ● Opioids should be used cautiously to prevent hypoventilation. Patient-controlled analgesia is preferred. ● Oxygen should be administered to prevent hypoxemia (low liter flow in chronic obstructive pulmonary disease).

Concurrent or Prior Pharmacotherapy Danger 1. Hazards exist when certain medications are given concomitantly with others (eg, interaction of some drugs with anesthetics can lead to hypotension and circulatory collapse). This also includes the use of many herbal substances. Although herbs are natural products, they can interact with other medications used in surgery.

THERAPEUTIC APPROACH ● An awareness of drug therapy is essential. ● Notify the health care provider and anesthesiologist if the patient is taking any of the following drugs: ○ Certain antibiotics may interrupt nerve transmission when combined with a curariform muscle relaxant. This may cause respiratory paralysis and apnea. ○ Antidepressants, particularly MAO inhibitors and St. John's wort, an herbal product, increases hypotensive effects of anesthesia. ○ Phenothiazines increase hypotensive action of anesthesia. ○ Diuretics, particularly thiazides, may cause electrolyte imbalance and respiratory depression during anesthesia. ○ Steroids inhibit wound healing. ○ Anticoagulants such as warfarin or heparin; or medications or herbs that may affect coagulation such as aspirin, feverfew, ginkgo biloba, nonsteroidal anti-inflammatory drugs, ticlopidine (Ticlid), and clopidogrel (Plavix). ○ Unexpected bleeding may result. DRUG ALERT MAO inhibitors, such as tranylcypromine (Parnate), phenelzine (Nardil), and selegiline (Eldepryl), must be discontinued before surgery or used with extreme cauti...