Dr. Yordy- Peri-Op - This is a lecture notes regarding things covered in nursing course PDF

Preview

Summary

This is a lecture notes regarding things covered in nursing course...

Description

Care of the Perioperative Patient Across Lifespan Dr. Yordy Priorities for the Preoperative Patient Chapter 15 Patient Safety  Number one priority  Preoperative checklist  Surgical safety checklists  Surgical Care Improvement Project (SCIP) o Mandatory o Infection prevention o Prevention of serious cardiac events o Prevention of VTE Safety- Informed Consent  Autonomously and cognitively grants permission  NOT the role of the nurse  Components o For the procedure itself o Anesthesia





o Blood products o Some instances, photos Inability to consent o Medical power of attorney o Emergency-2 providers can consent Obtaining consent o Surgeon o Per-op nurse o Safety-Time Out

Starts when the patient enters the facility o Wrist band  Procedure varies among facilities  Patient identifiers  Correct site-site marked by surgeon  Before incisions Overview  Preop- surgery scheduled to surgical suite  Nurse role: o Educator o Advocate o Promoter of health  Special emphasis on: o Safety o Advocacy o Patient education—validate, clarify, & reinforce 

 Patient readiness for surgery is critical to outcomes Patient Centered Collaborative Care  Assessment

1

History  Screen for problems that increase the risk for complications during and after surgery  Drug and substance abuse  Current medications GREAT table: 15.1  Last oral intake  Allergies-food and medication allergies  Anxiety and complication from previous surgeries  Blood donation  Advanced Directives o Discharge planning Patient Centered Collaborative Care  Assessment o Physical assessment/clinical manifestations  Baseline- COMPLETE ASSESSMENT before surgery  Vital signs  Height and Weight  Report any abnormal assessment findings  Cardiovascular  HTN  VTE Hx  Respiratory status  OSA  Kidney Fxn  Neurologic Fxn  Musculoskeletal  Nutritional status—malnutrition and obesity Patient Centered Collaborative Care  Assessment o Psychosocial assessment:  Level of anxiety  Coping ability  Support systems o Lab assessment before surgery provide baseline data!  UA  Type and screen  CBC  Clotting studies- PT, INR, aPTT  Electrolytes  BUN & Creatinine  Pregnancy test o EKG o Chest X Ray o

 Patient Centered Collaborative Care Nursing Diagnosis o Fear and Anxiety o Knowledge deficit Patient Centered Collaborative Care  Planning and Implementation 

2

Providing information  Coordinating care  Planning: expected outcomes  What is expected  Interventions  Teaching/educational checklist  Ensuring informed consent o If you have questions or believe the patient is not informed, call the physician  Time Out Patient Centered Collaborative Care  Interventions continued: o Patient self-determination:  Living will/advanced directive o Implementing dietary restrictions o

 NPO Administering regularly scheduled medications  Some are given with a sip of water: cardiac diseases, respiratory disease, seizures, HTN  Some HTN and antidepressants are held  ½ dose correction insulin (individualized) o Intestinal preps o Skin preps—body’s first line of defense  Hair clipping o Preparing for tubes, drains, and vascular access  Reduces anxiety Patient Centered Collaborative Care  Interventions continued: o Post op procedures/exercises  Checking dressings  Breathing/ IS  Leg exercise/SCD  Mobility Patient Centered Care  Interventions continued o Minimizing Anxiety  Restlessness/sleeplessness o Pre-op chart review  DOCUMENTATION o Pre-op patient preparation  Hospital gown  Valuables  ID band  Dentures/prosthesis/ hearing aids  Empty bladder o Preop medications o

  

3

Reduce anxiety promote relaxation prevent laryngospasms

 Reduce vagal induced bradycardia  Inhibit oral and gastric secretions  Prophylactic antibiotic o Transfer to the surgical suite Priorities for the Intraoperative Patient Chapter 16 Categories and Purposes of Surgery  Reasons for surgery  Urgency of surgery  Decree of Risk of surgery  Extent of surgery  Surgical settings o Inpatient o Outpatient o Ambulatory Members of the Surgical Team  Surgeon and surgical assist  Anesthesia providers  Perioperative nursing staff o Holding area nurses o Circulating o Scrub nurses o Specialty nurses Layout  Helps prevent infection by reducing contaminants through air exchanges in the room, maintaining recommended temperature and humidity levels, and limiting the traffic and activities in the OR  Located in mainstream hospital- close to PACU and supportive areas  Clean and contaminated areas separate  Minimally invasive and robotic surgery  MIS- reduced blood loss, faster recovery time, and less pain o Endoscope  Viewing  Organ removal  Injecting gas/air o Chance to convert to open surgery  Robotic Health and Hygiene of the Surgical Team  People are a source of contamination o Skin o Hair o Airway  Policies  No open wounds  No infection  Personal hygiene Surgical Attire  All members must where scrub attire  Clean (not sterile)

4

 Worn to reduce contamination and risk for infection from areas outside of the surgical setting  Change in OR suite locker  Hair covered  Protected eyewear  Masks  Sterile gown-scrubbed in sterile field Surgical scrub  Surgical scrub after putting on a mask and before putting on sterile gown and gloves  Does not make skin sterile  Reduces the number of organisms from the hands, arms, and nails  Antimicrobial solution  Vigorous rubbing for fingertips-elbow o 3-5 minutes  Gown, gloves, and material used in the operative field must be sterile Anesthesia  Reduces or temporarily eliminates sensory perception  With or without loss of consciousness  Purpose o Block nerve impulse transmission o Suppress reflexes o Promote muscle relation o Achieve a controlled level of unconsciousness  Anesthesiologist selects type based on procedure and patient  Table 16.2  Prior to surgery each patient is given a preoperative physical exam and eval by the anesthesia team General Anesthesia  Reversible loss of consciousness o Inhibiting neuronal impulses in several areas of the CNS  Analgesia- pain relief/suppression  Amnesia- memory loss of surgery  Unconsciousness and loss of muscle tone  Stages & Emergence o Emergence depends on anesthetic, duration, reversal agent  Administration o Inhalation o IV o Muscle relaxants Let’s think for a minute  Look at table 16.3  Amnestic  Analgesics  Muscle relaxants General Anesthesia Complications  Range from minor to death  Malignant hyperthermia  Overdose of anesthetic  Unrecognized hypoventilation  Intubation complication

5

Local or Regional Anesthesia  Briefly disrupts sensory nerve impulse transmission from a specific body area/region  Motor fxn may/may not be affected  Conscious  Local-skin or infiltration in tissue  Regional- blocks multiple peripheral nerves o Think of spinal, epidural, caudal, and nerve blocks Local  Complications:  For local: edema and inflammation o May have abscess Regional Anesthesia  Nurse role:  Assist the physician  Check for sterile technique  Provide emotional support  Stay with the patient  Offer information & reassurance  Position the patient Complications of Regional Anesthesia  Anaphylaxis  CNS disturbances o headache  Cardiac depression o Decreased BP  Rare: cardiac arrest  Nurse assessment: o Restlessness o o o o o o o o o o

Excitement Incoherent speech Blurred vision Metallic taste Nausea Tremors Seizures Increased pulse Increased Respiration Hypotension

Conscious Sedation/Moderate Sedation--- Book lists as: Monitored Anesthesia Care  IV delivery of sedative, hypnotic, and opioid drugs to reduce sensory perception  Patient can maintain a patent airway  Amnesia is short  Most states, RN can administer under physician order o Monitors during and after delivery  Common medications used: o Diazepam (Valium), midazolam (Versed), propofol (Diprivan), and morphine sulfate Airway Management  Oxygenation during procedure

6

Not just for general anesthesia Airway complications: o Laryngospasms o Bronchial intubation o Tracheal and esophageal perforation o Aspiration Nursing Diagnosis  Impaired gas exchange related to anesthesia, pain, reduced respiratory effort o Goal is to prevent injury relating to poor gas exchange o Monitoring the patient o Breathing, circulation, and cardia rhythms o BP and HR monitoring every 5 minutes  Common Surgical Positions (figure 16.7)  

Patient Centered Collaborative Care  History o Ensure correct identification of the patient o Ask the patient what procedure they are having done o Validate site o TJC: Wrong Site, Wrong Procedure, Wrong Person o Allergies o Proper attire o Skin integrity-older patients  Medical Record review o Assess and plan specific care during and after surgery o Advanced Directive Patient Centered Collaborative Care  Risk for perioperative positioning injury related to improper positioning o Patient cannot guard against nerve or joint damage and muscle stretch or strain o Pressure ulcers o Extra padding for frail, bruised, injured skin o Supine then repositioned  Proper position ensured by assessing for: o Anatomic alignment o Circulation and breathing

7

o Protection of skeletal/neuromuscular structures o Exposure of op site and IV site o Access to the patient by anesthesia provider o Patient comfort safety and dignity Patient Centered Collaborative Care  Risk for infection related to invasive procedure o Identify patients with health problems o Sterile technique o Skin and tissue closures

o o o

 Hold wound edges in place until wound healing is complete  Occlude blood vessels, preventing poor clotting and hemorrhage  Prevent wound contamination and infection Antibiotics Pressure dressings: prevent poor clotting and bleeding Drains- remove secretions Priorities for the Post-Operative Patient Chapter 17

Overview  Postanesthesia care unit (PACU)  Room set upo Cubicles o Equipment: cardiac monitors, pulse ox, airway equipment, emergency medications  Hand-off communication  PACU nurse is VERY skilled o Anatomy and physiology o Anesthetic agents, pharmacology, and pain management o Extubation o Surgical procedures o ACLS o Critical decision-making skills Patient Centered Collaborative Care  Surgical team’s report helps with plan of care  Review the medical record for physical condition, patient history, and emotional status  If inpatient, the surgical and anesthesia info is incorporated to the plan of care  Understand the general potential complication of surgery Patient Centered Collaborative Care  Physical assessment and clinical manifestations o Assess patient o Document findings o Monitor VS o PACU team determines patient readiness for discharge from PACU  The anesthesia provider will discharge to the hospital unit or to home  Sometimes the surgeon or nurse discharges the patient once discharge criteria has been met

Patient Centered Collaborative Care

8

Respiratory system o Most critical assessment to perform after surgery o Immediately assess for a patent airway and adequate gas exchange o If wearing oxygen, documents delivery device and concentration o Rate pattern and depth of breathing o Assess breath sounds o Accessory muscle use o Snoring or stridor  Once the patient goes to the inpatient unit still complete a thorough respiratory assessment Patient Centered Collaborative Care  Potential for hypoxemia related to the effects of anesthesia, pain, opioid analgesics, and immobility o Airway maintenance- oral airway o Monitoring o Might need reversal agents: flumazenil (Romazicon) o Hypothermia-increases O2 demands o Position-semi fowlers o O2 therapy for hypoxemia o Breathing exercise- splint incisions 

 IS; suctioning o Movement Patient Centered Collaborative Care  Cardiovascular system o VS and heart signs on admission and Q15min  Once patient is more stable, the VS will transition to Q30 for an hour, then every hour for 4 hours, then every 4 hours til home o Review trends o Report blood pressure changes higher/lower than baseline  Good rule of thumb-20% above/below baseline o Cardiac monitoring- telemetry  Pulse deficit could indicate a dysrhythmia o Peripheral vascular assessment  Preventive measures to prevent clots prior to surgery (TED hose, SCD pumps) should be used at least 24 hours post-surgery Patient Centered Collaborative Care  Neurologic system o Cerebral functioning and LOC or awareness must be assessed in all patients who have received general anesthesia or any type of sedation o Lethargy o Restlessness o Irritability o Compare the baseline neurologic status o Motor function and sensory function after general anesthesia o Motor/sensory after spinal and epidural  hematoma Patient Centered Collaborative Care  Fluid, electrolyte, acid-base balance o Fluid volume deficit/overload may occur

9

Electrolyte imbalances Intake and output- at least 24 hours post op  Kidney & heart disease pts need a longer output measurement per. o Hydration status o IV fluids o Acid base balance- affected by the:  patient’s respiratory status  Metabolic changes in surgery  Loss of acids/bases in drainage  Lab Assessments: table 17.1 Patient Centered Collaborative Care  Kidney/Urinary system o Urine control o Inspect, palpate, percuss o Straight cath/indwelling catheter  GI system o Post op nausea/ vomiting o Intestinal peristalsis  Paralytic ileus o Constipation  Results from anesthesia, analgesia, decreased activity, decreased oral intake Patient Centered Collaborative Care  Normal wound healing o Incised tissue regains blood supply o o

o Sanguineous or serous-sanguineous o Pink incision line o Slight swelling  Impaired wound healing o Wound dehiscence o Evisceration o Often occur the 5th-10th POD o Obese patients Patient Centered Collaborative Care  Potential for wound infection/delayed healing related to wound location, decreased mobility, drains/drainage, & tubes o Nursing assessment of surgical area critical  Assess wound (if visible); assess dressing if wound covered o Wound care o Dressings-change by surgeon, 1st  Sometimes staples open to air  Vary due to procedure type o Sutures/ staples removed 5-10 days after surgery  Remove every other first o Drains o Drug therapy- antibiotic therapy o Debridement o EMERGENCY- call MD for dehiscence and evisceration

10

Patient Centered Collaborative Care  Discomfort/Pain Assessment o Subjective experience o Related to surgical wound, tissue manipulation, drains, positioning, ET tube, patient’s experience with pain o Rate pain before and after intervention o Mobility o Pain reaches its peak POD 2 (usually) Patient Centered Collaborative Care  Acute pain related to the surgical incision, positioning during surgery, and ET tube irritation o Drug therapy o Positioning o Relaxation techniques o Diversion o The patient with optimal pain control is better able to cooperate with therapies and exercise to prevent complications o PACU-IV meds in small does Opioid analgesics- first 24-48 hrs acute pain  Switch to PO once tolerating oral o Opioid antagonist- Narcan (naloxone) Pain Management  Essential  Patient’s perception of pain  PCA  Polypharmacy o NSAIDS o Opioids o Local anesthetics Patient Centered Collaborative Care  For the older adult- preventing infection: o Adequate hydration- Cardiac output o Airway patent- adequate oxygenation o Conserve patient energy o

o Aseptic technique o Protect fragile skin Patient Centered Collaborative Care  Heading home o Home management o Discharge plans o Education  Preventing infection  Care and assessment of surgical wound  Drain and catheter management  Nutrition  Pain management  Drug therapy

11

o

12

 Activity Social work...