Nursing Care Periop Notes[ 11248 ] PDF

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Introduction Perioperative Period is the time period surrounding a patient's surgical procedure; this commonly includes ward admission, anaesthesia, surgery & recovery. Preoperative, intraoperative, post-operative Patient journey As early as the assessment of symptoms & decisions to operate, hospital management, home recovery & rehabilitation 1.Home, 2. Pre- Hospital (Drs office, surgeon consult, preadmission clinic). 3. Hospital (Admission, procedural n endoscopy rms, interventional suits, medical imaging, preoperative holding, anaesthetic bay, operating room, post anaesthesia care unit PACU, stage 2-day surgery or ward), 4. home, postoperative follow up community health services. - Assessment of symptoms & decision to operate. Period of hospital management. Period of home rehab Perioperative Nursing A professional nurse who provides complex care for patients in a high dependency situation. Advocate 4 the pt Philosophy: Safe physical environment, holistic, protect pt from adverse advents, gaining optimal pt outcome. Promoting the knowledge and skills of all multidisciplinary team members to enable cost effective research health care The acknowledgement of the dignity of persons with divers physical, emotional and cultural backgrounds Perioperative Admission, anaesthesia, surgery, recovery. Operating Room Room within a hospital within which surgical operations are carried out. Surgery “hand work” is the medical speciality that treats diseases or injuries by operative, manual and instrumental treatment n place Models of Theatres The operating theatre and layout must allow for the day to day workload and the fluctuations of patients as well as allowing for the additional emergency surgery. There are 3 different layoutsRacetrack- Single Corridor- Small Cluster model Racetrack Model In this model OR’s are unusually place around a corridor that contain equipment and supply areas. An outside “racetrack” may be used to transport contaminated materials. AIM: manage use of each corridor reducing the presence of contaminated items without duplicating equipment supplies and staff. Single Corridor Model In this mode there is a central corridor that divides the OR’s and storage areas allowing passage of ALL patient’s staff supplies and equipment. Lots of cons about this. If corridor is not wide enough clean and contaminated equipment may be in close proximity patients may also be exposed to distressing sights/sounds. Small Cluster Model

This model combines 2 – 4 OR’s with a shared sterile stock room. Disadvantages include increased cost due to having to duplicate sterile stock Departments Ancillary services diagnostics & testing- X-Ray, Pathology, Blood Bank. Departments- ED, ICU. Sterilisation- CSSD/ TSSU X-Ray dept Why? To check placement of plates etc. Cancer surgery complete excision of tumours. Pathology – to allow for testing of tumours immediately. Blood bank In case of haemorrhaging. ED – For emergency surgery. ICU- For post-surgery care Floors, Walls, Ceilings Seamless, Waterproof, Easy to clean, Stain Proof, Hard, Non- Reflective, Non – porous, Fire resistant Lighting Operating lights are ceiling mounted directly above table . Provide shadowless light, LED, allows for manipulation by scrubbed team, Surgical team may also wear headlights Communication Systems Stentofon (intercom system) • Telephone • Overhead paging • Pagers • Alarm systems- call light • Resuscitation bells • Computer systems Layout Traffic control- 4 Zones 1. Transition – ie changing rooms 2. Unrestricted – preop n recovery, ALL personnel including those wearing street clothes. 3. Semi- peripheral support areas traffic is limited; appropriate attire is worn. 4. Restricted- Scrub areas, operating room Conditions Humidity 50-60% this is to reduce bacterial growth and to suppress static electricity Temperature 20-22 degrees to reduce metabolic demand comfort of operating team, inhibit bacterial growth. May need to be adjusted for other types of surgery. Burns theatres are hot 20-22 Air Control To reduce the spread of airborne bacteria. Positive pressure which forces air from the OR out into external environment. HEPA filters (High Efficiency Particulate Air) 20-40 room exchange of air per hour. Operating Team Anaesthetist DR - What type of anaesthetic to be used, Monitoring and maintaining airway and circulation, Management of pain, nausea and vomiting, Post op nursing care requirements, Documentation? Anaesthetic Tech - Helps Anaesthetist prepare equipment, Checks pt into anaesthetic room, Checks equipment thoroughly throughout the day, Restocks all supplies at the end of the day Surgeon Dr

Preparation of the patient, Scheduling of elective lists, booking of emergency cases, Instrument and Equipment required, Infection control, Documentation Perfusionist - Assists the anaesthetist during cardiac bypass surgery, Responsible for the Cardiac bypass machine set up, Adjustment of the delivery of key components on commencement, during and completion of the bypass procedure, Documentation The Orderly, Patient transport and transfer, Assistance with patient positioning, Assistance with cleaning and waste disposal, Delivery of urgent specimens and blood products Orderly - Pt transfer, positioning, waste disposal & cleaning, delivery of urgent specimens/ blood products Orthopaedic Tech - Care & maintenance of instruments, Ordering instruments & prostheses, Assistance with positioning, Liaising with product reps Radiographer - Pre, Intra and Post Op X-Rays, Intraoperative Images CSSD Staff - Provision of sterile supplies, involved in the packing, cleaning, checking and disinfecting and distribution of instruments Supportive staff - Clerical, cleaning, uniforms, products rep Additional support services - X-ray department, pathology, blood bank, ED, ICU, central sterile services (CSSD)/ Theatre Sterile Supply unit (TSSU) Product Representative - Suppliers of instruments, equipment & consumables, assist with staff education & use of items provided. Nurse Manager - Overall coordination of the operating suite Responsible for; Staffing, Budgeting, Purchasing new equipment, Internal and external liaison, Performance management, Clinical Standards Floor Coordinator Nurse - Staff allocation, Scheduling of elective lists & obtaining necessary equipment, Scheduling emergency cases in partnership with duty anaesthetist, Conflict resolution Staff Development Nurse - Orientation to the suite, Allocation of preceptors, Performance management of graduate nurses, Clinical support, In service sessions Pre – Op Nurse - holding bay nurse, Pre op checklist in holding bay, required documents ie X-Rays, Blood results etc, All info is recorded and correct – allergies, fasting times , All other documentation – consent, pre op paperwork, fluid balance chart, surgical safety checklist. Anaesthetic Nurse - Preparation of the anaesthetic induction room and associated equipment, Assistance with patient transfer, Application of monitoring devices, Assistance with induction, intubation, maintenance and emergence from anaesthesia, Collaborate with anaesthetist and PACU staff, Documentation Instrument/ Scrub Nurse - Preparation & maintenance of sterile field, accuracy of surgical count, Anticipation of surgical events & requirements. Application of surgical dressing & wound drainage devices, Documentation of intra op care. Systematic & Planned Approach, Communicate and participate (eg ID & Consent), Supplies available, monitor patient transfer and positioning. Sterile set up, Surgical count, remain vigilant (recognise & respond), Monitor aseptic -

technique & act, Processing of reusable items. Checks & prepares equipment, Surgical scrub, Gowning & gloving, Create & maintain sterile field, Prepares/applies skin prep, provides patient drapes, provides instrumentation, anticipates intraoperative events and accordingly, monitors sterile field, Initiates the 2nd/3rd surgical count. Assists dressing of wound, Assists with removal of the drapes. Assists with the attachment of wound drainage systems. Signs count sheet. Prepares instrument trolley for decontamination. Disposes of sharps. Disposes of waste. Considerations- Passing instruments- deliberate & committed manner, small amount of pressure, slight pause as surgeon takes the instrument ensure a proper grasp. Minimising handling of instruments, place instruments where they will be needed. Place with purpose ready to use. Sharps facing back towards nurse, blade facing down if receptacle cant be used. Place items as they are positioned for use. Circulating/ Scout Nurse - Patient safety, Patient positioning, The accuracy of the surgical count, Provision of sterile supplies, Intraoperative documentation, Post op transfer, Handover to recovery room nurse outside sterile area. Practice Standards, Principles (eg asepsis, infection control), Anatomy and Physiology, Surgical procedures and instrumentation, OH&S (personal protective equipment), Care, cleaning maintenance of instruments, Medico Legal (consent, documentation). Systematic and Planned Approach, Communicate and participate (eg ID & Consent), Supplies available, monitor patient transfer and positioning, Sterile set up, Surgical count, Remain vigilant (recognise and respond), Monitor aseptic technique and act, Processing of reusable items. Checks and prepares the operating theatre and required equipment, Assists the instrument nurse and surgical team to gown Opens and dispenses items to create a sterile field (checking integrity), Records and surgical count, Checks the patient prior to the commencement of anaesthetic, Assists with patient positioning, Applies the diathermy plate, Arranges theatre equipment, Turns on the operating, Assists the surgeons to gown, Receives the skin prep dish, Assists with positioning the surgical drapes, Attaches the diathermy plate and electrode to the machine, Attaches the suction tubing to the suction canister, Records intraoperative events, Monitors blood loss, Anticipates surgical events and acts accordingly, Sends for the next patient, Documents the surgical count, Assists with removal of the drapes, Assists with the attachment of the wound drainage systems, Assists with the patient transfer, Transports the patient to the recovery room and provides a handover Assists with the end of case clean-up Recovery Room Nurse/ PACU - ABC Maintenance of the patient’s airway, breathing & circulation, Pain control, Relief from nausea and vomiting, Assessment of the wound site, Management of fluid balance, Documentation, Intra-Operative Nursing Responsibilities

Preoperative ADPIE, Holding bay, Evaluation, Anaesthesia/ bay room, Pre-meds (Sedatives/tranquilizers, Narcotics, Anticholinergics, Antiemetics), airway management, induction, intubation Nurse Introduce, warmth, Id pt, admitting pt, Documentation, Consents, Allergies/ Sensitivities, preoperative fasting, pre-meds n medications, Document Implants, patient warming, removal of Jewellery fake nails, piercings, Tests (blood, urine, X-ray, ECG), Base line Obs. The peri-op nurse is accountable & responsible for patient care, whether accomplished personally or by another

perioperative team member. Must be flexible Diverse, Roles incorporate both technical & Professional. COMUNICATION! Pre-Op Evaluation/ Assessment Patient Hx, Prior Hx of Difficult Intubation prior surgeries, Safest method decided by anaesthetist, Any tumours of head or neck, Arthritis, Pregnancy, Mobility of cervical spine Goals of pre-op assessment 1.Pt understands procedure& anaesthetic to be given, side effects & alternative treatments, 2. Pt is medically fit 4 surgery & anaesthesia or investigations, 3. Verbal, written info covering all aspects of the surgery, 4. Consent, 5. Pt agrees to be a day pt if procedure is suitable Pre- Op Checklist Allergies, URN, ID, Vitals, weight, prosthetic devises, contact lenses, eye prosthesis, hearing aids, prosthetic limbs, Teds/ Flowtrons, Communication, Skin integrity, Blood group, education of procedure ect, pregnancy status, urinalysis, Pt labels page, ID check, Id bands (not on op limb), Site marked, Foods, fluids consumed, X-rays to theatre, Teeth plate caps crowns loos teeth bridge, dentures, catheter insitu, prep op site shaved ect, chlorhexidine shower, med record with pt, Bowel prep, jewellery taped/ removed, makeup, nails polish, hairclips removed, pre-meds given, Pressure injury risk score, Signed, Dated RN, Location Forms Bone declaration form, Refusal 4 blood transfusion, Consent forms Day surgery ward Pre-Op or Holding bay, Anaesthetic Bay/ room, Theatre Pre op preparations/ Considerations ASA grade- physical status classification to check Pt suitability for surgery. Diabetes under control, Pre op bathing using antiseptic solution, hair removal, sight marking, fasting, tests (ECG, bloods, X-rays), investigations, special needs eg interpreter carer or support, culture sensitivities, smoking habits ascertained prior to surgery, obesity requirements, Consents signed, Discontinuation of certain meds ie blood thinners, metformin, gingko biloba, BGLs done, DVT prevention in place, Assessment Data Collection gathered in preop bay/clinic/interview, Physical assessment, baseline obs, Will they be able to cope at home post-surgery, psych assessment, how they are feeling Diagnosis Prevention eg falls risk (diagnosing risk) Plan Care that prescribes the interventions to attain the planned outcome, Eg the periop team will put flotrons on pt therefore reducing DVT risk, the periop team will ... expected outcome the pt will be injury free. Intervention To monitor constantly the physical and psychologic responses of patients to care. Nurses control environmental factors that affect the outcomes of surgical intervention, documentation Evaluation Patient is observed during the surgical procedure and evaluated for responses to all interventions, Patient is normothermic, Patient is free from injury

Pre-Meds Decrease anxiety, reduce bronchial secretions, analgesia, amnesia. Administration Either IM, IV, intranasally or PO with 15-30mls water. Pt usually prefers oral pre-med. Absorption & uptake are more predictable than that with IM injection. Before pre-med given, last mint questions, consent forms verified. Usually given 30-90minutes before surgery OR IV in holding bay or in the OT. Nothing by mouth (NPO) for 4-6hours minimum before elective surgery, clear liquids shorter fasting time. Sedatives and Tranquilizers - Calm hypnotic state, sedation & amnesia - Med- Benzodiazepines- Valium, Midazolam, Barbiturates- sleeping pills Narcotics - Raise the pain threshold, lower metabolic rate. - Decreases the amount of anaesthetic required - Med- Morphine/Fentanyl Anticholinergics - Interfere with stimulation of vagus nerve - Prevent vagal mediated hypotension, cardiac arrythmias, bradycardia - Decrease oral & resp secretions - Increase heart rate - Med- Atropine sulphate, Glycopyrrolate Antiemetics - Minimise nausea and vomiting - May potentiate (increase the power/ effect) the effects of narcotics - Often used in combination with other drugs - Med- Droperidol, Dexamethasine, Ondansertron

Anaesthesia Definition Reversible, unconscious state. Affects CNS – sensory pathways. Allows more time to operate, new procedures as a result Greek word anaesthesia which means no sensation. Implies unconscious. 3 Components of analgesia Muscle relaxation/ Paralysis, sedation, analgesia Characterized by Amnesia (sleep), Analgesia (freedom from pain), Depression of reflexes, Muscle relaxation Pre- Op Evaluation Pt Hx, Prior Hx of difficult intubation, Safest method, most pleasant made by the anaesthetist, Pt & surgeon, Tumour of Head n Neck, Arthritis, Pregnancy, Mobility of cervical spine & length& thickness of neck, Family Hx of Malignant Hyperthermia, Mallampati classification Types of Anaesthetics - Regional (A region on the body i.e. epi Dural). Local, General (GA), Sedation/ analgesia Regional Anaesthesia

A reversible loss of sensation in a specific area or region of the body when a local anaesthetic is injected to purposefully block or anesthetize nerve fibres in and around the operative site. e.g. spinal, epidural, and major peripheral blocks Local Anaesthesia Administration of an anaesthetic agent to one part of the body by local infiltration or topical application. Eg teeth, mole removal. Requires nurse monitoring vitals prevent reaction. GA/ Sequence/ Types GA General Anaesthesia Reversable unconscious state, affects CNS sensory pathways. Characterised Amnesia (sleep), Analgesia (freedom from pain), Depression of reflexes, Muscle relaxation Sequence of GA Arrive in OR Suite. Pt Identified – Name, DOB, URN. Charts check for signed consents. Latest lab tests results reviewed. Depending on hospital IV infusion may be started in the pre op area. In OR – appropriate monitoring connected. IV access. Before induction- pt preoxygenated (denitrogenated) using a mask with 100%O2 for 3 to 5 minutes – washout of nitrogen gas – O2 in lungs. Opioids and benzodiazepines administered at this time, non-depolarizing muscle relaxants for intubation Process of GA 3 Phases 1. Induction *Preoxygenation- reserve supple, *Dedation agents- midazolam & narcotic, *Propofol-anaethesia, *ventilation with bag/ mask & oxygen- manages apnoea, *long acting muscle relaxantrocuronium, *Intubation with ETT- ventilation, *Inflation of ETT cuff- seals airway, *ETT securedtape, *Confirmation of ETT location- bilateral lung inflation, Co2, stethoscope monitoring, *Attachment of ETT to ventilator 2. Maintenance *Delivery of oxygen, nitrous oxide & volatile agent sevoflurane- continuing anaesthesia, *Continuing muscle relaxant, *Haemodynamic monitoring temp, IV- monitor status access for drugs, * continuing analgesia- pain relief, *Near completion of the procedure. 3. Emergence *Reversal of muscle relaxants using neostigmine & atrophine- allow spontaneous respiration, *switching of inhalation agents administering 100% oxygen- washes residual anaesthetic agents, *Pt begins to “emerge, pt ready to leave, *Suction of oropharynx, *Extubating when Pt is breathing spontaneously, responding to verbal commands & is hemodynamically stable, *Monitor until transfer to PACU- suction & oxygen on standby. 4. Recovery is the 4th phase

Types of GA IV, Inhalation, Combination of both - Med- Propofol with 30% to 40% 02 & N20, amnestic drug such as midazolam, analgesic such as fentanyl or morphine sulphate, a muscle relaxant such as recuronium (blocks transmission of nerve impulses to the muscles – neuromuscular blocking agent. Does not affect consciousness or provide pain relief) - Maintenance- Oxygenation, Unconsciousness, Analgesia, Muscle relaxation, Control of autonomic reflexes Inhalational agents - Med- Sevoflurane, Nitorus oxide (gas) used as adjunct, poor relaxant minimises nausea/vomiting, Med- Isoflurane (vaporiser) low toxicity, expensive cardiac stability and rapid induction and recovery, Med- Desflurane - Maintenance- Oxygenation, Unconsciousness, Analgesia, Muscle relaxation, Control of autonomic reflexes Intravenous agent - Med- Thiopentone (barbiturate), (rare but used in patients with unstable BP) rapid induction. Med- Propofol Muscle Relaxant - Depolarising Med- Suxamethinium – acts within seconds last approx. 5 mins - Non depolarising Med- vecuronium acts over 2-3mins lasts 30-60mins Gaseous Agents- Med- nitrous oxide, Dissociative anaesthetics- Med- Ketamine

Pre-Operative evaluation Patient History, Prior History of Difficult Intubation, Safest method? Most pleasant made by anaesthetist, patient & surgeon, Tumour of Head & Neck, Arthritis, Pregnancy, Mobility of cervical spine and length and thickness of neck, Familial Hx, Med Hx, Surg Hx, Social Hx (drugs, alcohol, smoking, base line state, planned procedure, allergies, drug sensitivities, current meds, herbal supplements, Hx of anaesthetic experience, psychological makeup. Assessment of the airway - Length of incisors, mobility of cervical spine, length, thickness of neck, Mallampati score, mandible mobility. Mallampati classification- ease of intubation, open mouth class 1 wide- class 4 partial Non depolarising muscle relaxant. Depolarising agent - short lasting, quick action Adjuncts to general Anaesthesia Opioids Meds- Fentanyl, Sufentanil, Morphine sulphate, A...