Perioperative Nursing Lecture Questions and Review PDF

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Notes about nursing interventions provided for surgical patients and signs and symptoms, complications, case studies, question and answer....

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Perioperative Nursing Perioperative Nursing Definition of Surgery  Surgery is any procedure performed on the human body that uses instruments to alter tissue or organ integrity. Perioperative Nursing  Connotes the delivery of patient care in the preoperative, intraoperative, and postoperative periods of the patient’s surgical experience through the framework of the nursing process. Practice Areas  Hospital operating rooms  Interventional radiology suites  Cardiac cath. Labs  Endoscopy suites  Ambulatory surgery centers  Trauma centers  Pediatric specialty centers  Physician offices Perioperative Nursing: Purpose  Diagnostic-Allows to confirm or establishes diagnosis  Corrective- Excision or removal of diseased body part  Reconstructive-Restore function or appearance to traumatized or malfunctioning tissues  Ablative – Removes a diseased body parts  Palliative – Relieves or reduces pain or symptoms of a disease; it does not cure  Transplant – Replaces malfunctioning structures  Cosmetic- Performed to improve personal appearance Perioperative Nursing: Urgency  Emergency - To preserve function or the life of the client  Elective – Surgical intervention is the preferred treatment for a condition  Urgent – Necessary for client’s health to prevent additional problem  Required – has to be performed at some point Perioperative Nursing: Degree of Risk  Major  Minor  Age  General health  Nutritional Status  Medications  Mental status  Self-fulfilling prophecy Perioperative Nursing: Phases  Preoperative phase o Begins when the decision to have surgery is made and ends when the client is transferred to the OR table.  Intraoperative phase o Begins when the client is transferred to the OR table and ends when the client is admitted to the PACU.  Postoperative phase o Begins with the admission of the client to the PACU and ends when the healing is complete. Preoperative Nursing Care: Assessment Responsibilities of the Perioperative Nurse:  Patient Assessment  Physical Problems  Emotional Aspects

 Understanding of surgery/consent  Legal requirements for chart completion  Read and interpret lab results  Perioperative Teaching Preoperative Nursing Care: Assessment  Cardiovascular system  Respiratory system  Renal system  Neurological system  Musculoskeletal system  Nutritional status  Gerontological considerations Home Medication Implications  Antibiotics  Antidysrhythmics  Anticoagulants  Antihypertensives  Corticosteroids  Insulin  Nonsteroidal anti-inflammatory drugs  Herbal therapies Preoperative Nursing Care: Gerontological Considerations  Cardiovascular System  Respiratory System  Nervous System  Renal System  Gastrointestinal System  Musculoskeletal System  Integumentary System Preoperative Nursing Care: Psychosocial Considerations  Level of anxiety  Coping ability  Support systems Decreasing Patient Anxiety  Therapeutic communication o Early teaching and counseling o Diversional activities o Encourage family support o Encourage verbalization of fears/loss of control o Deep breathing, medications, imagery, music o Spiritual support (communion, bible reading, prayers, rituals, chants) o Inform family where to wait, buy food, bathroom, phone, overnight and visiting policy o Possible use of sedative or tranquilizer or PRN medications o Dolls/favorite toy for children Pediatric Considerations  Child’s comprehension and response based on developmental age  Remain alongside child until anesthetized o Keep room quiet during induction o Provide child security objects (teddy bear) until induction complete o Behavior during induction the same during emergence:

o Calm, reassuring care  Alert parents of delays Nursing Diagnoses  Knowledge deficit  Anxiety  Ineffective coping  Anticipatory grieving  Disturbed body image  Disabled family coping  Powerlessness  Risk for ineffective airway clearance  Fear  Disturbed sleep pattern Preoperative Nursing Care: Teaching  Begins with assessment  Focuses on information that will increase patient’s familiarity with procedural events.  Discuss surgical procedure and expectations  Adapt teaching to client’s ability to understand  Teaching clients about their surgical procedure and expectations before and after surgery is best done during the preoperative period. Preoperative Client Preparation  Clothing removed/don patient gown  Jewelry removed including body any piercing/s  Prosthesis: dentures, wigs, limbs  Aides: hearing, glasses, cane  Arm bands: identification, code status, blood bracelet, fall risk status bracelet  Misc.: contact lenses, hairpins  Nail polish, artificial nails Labs  Urine – UA  Hematocrit – Hct  Hemoglobin – Hgb  White blood cell count – WBC  Prothrombin time/ pro time – PT  Partial thromboplastin time, activated – aPTT  International Normalized ratio – INR  Chemistry: electrolytes - Na, Cl, K, Glucose, CO2  Creatinine  Blood urea nitrogen – BUN  Serum pregnancy test Radiographs/Optional tests  Chest x-ray – CXR  Electrocardiogram – EKG  Arterial blood gas – ABGs  Pulmonary function tests – PFTs  Films for area of surgery - x-rays, MRI, CAT scan Preoperative Teaching Plan Includes:  Preoperative medication  Post-operative pain control  The post anesthesia recovery room or post-surgical area  Frequency of assessing vital signs and use of monitoring equipment

 Post-operative respiratory care  Information about intravenous (IV) fluids, other lines and tubes such as nasogastric tubes  Preoperative teaching time: gives the client the chance to express any anxieties and fears  Emergency surgery: time for explanation is unavailable or diminished Pre-operative Checklist  Form lists requirements before patient goes to OR  Documents diagnostic tests completed  Documents pre-op medication given  Documents VS  Documents safety data o ID band in place; 2 identifiers o Jewelry removed o Last void o Dentures removed o Informed consent verified o Patient Allergies Preoperative Nursing Care: Medications  Prior to administering – check permits  Purpose  Determinants of drug choice Preoperative Nursing Care: Medications  Sedatives/hypnotics Tranquilizers-Ativan, Versed, Valium  Opiate analgesics- morphine  Anticholinergics-Atropine sulfate, Atarax  H2o blockers.- Tagamet, Zantac  Antiemetic- Reglan, Phenergan Informed consent  Informed consent must include three conditions  Surgeon responsible for obtaining consent o Nurse as witness to signature and knowledge  Permission may be withdrawn at any time  No sedation  Legally appointed representative of family may consent  Medical emergency may override consent Perioperative Nursing Roles  Staff education  Client/family teaching  Support and reassurance  Advocacy  Control of the environment  Provision of resources  Maintenance of asepsis  Monitoring of physiologic and psychological status Transportation to Surgery  Inpatient  Ambulatory care or a.m. admission  Report to receiving nurse Intraoperative Phase: Surgical Attire  Gowns, Gloves, Masks, Hair Covering, Protective eyewear, Shoe covers Intraoperative Goals: Safety

 Provide safe client care  Provide a safe environment  Provide safety for staff Surgical tables Intraoperative Nursing Care: Surgical Asepsis  Ensure sterility o Alert for breaks o Surgical field-defined  Infection control practices  Physical layout of surgical suite  Protocols: distance, doors, dress Intraoperative Safety: Client  Correct patient, correct surgery, correct side: Time Out  Positioning: padding, alignment, eyes  Injury: burns  Sponge, Needle, Instrument counts  Fall prevention-safety straps  Provide for quiet environment during induction  Document events, patient care given  Provide for a safe transfer to recovery room Intraoperative Phase: Surgical Team  Surgeon  Anesthesiologist  Scrub Nurse  Circulating Nurse  OR techs Time Out Basics of Anesthesia Intraoperative Phase Anesthesia  Factors influencing dosage and type: o Type and duration of the procedure o Area of the body being operated on o Whether the procedure is an emergency o Options of management of post-op. pain o How long it has been since the client ate, had any liquids, or any medications o Client position for the surgical procedures Types of Anesthesia  General- method use when the surgery requires that the patient be unconscious and/or paralyzed.  A general anesthetic acts by blocking awareness centers in the brain so that amnesia (loss of memory), analgesia (insensibility to pain), hypnosis (artificial sleep), and relaxation (rendering a part of the body less tense) occur.  Phases of general anesthesia o Induction o Maintenance o Emergence  Types of general anesthesia o IV technique o Inhalation technique o Combination of the two General Anesthesia: Intravenous

Intravenous Agents  Thiopental Sodium (Pentothal) but is commonly called “Sodium Pentothal” by patients (class: barbiturate)  Diprovan (Propofol) o Rapid acting o Monitor vital signs o Respiratory depression General Anesthesia: Inhalation Agents  Inhalation most controllable method; lungs act as passageway for entrance & exit of agent  Gas Agents : Nitrous Oxide o Must be given with oxygen o Require assisted to mechanical ventilation o Frequently shiver o Taken in and excreted via lungs o Examples: halothane, enflurane… General Anesthesia: Endotracheal Intubation (maintain airway patency/promote oxygenation) Adjuncts to General Anesthesia  Hypnotics (Versed) o Also used for conscious sedation  Opioid Analgesics (Morphine, Fentanyl) o Respiratory depression  Neuromuscular Blocking Agents o Causes muscle paralysis o Examples: Rocuronium, Succinylcholine Potential General Anesthesia Complications  Overdose (consider risk factors)  Hypoventilation postoperatively  Intubation related: sore throat, hoarseness, broken teeth, vocal cord trauma  Malignant Hyperthermia o Genetic predisposition o Triggered by anesthetics such as Halothane Malignant Hyperthermia  Hypermetabolic disorder if untreated will result in death  Usually triggered through use of commonly used general anesthetics and succinylcholine  Symptoms: increased body temperature, unexplained tachycardia, muscle rigidity, cyanosis  Treatment: o Dantrolene o Cooling blanket o Monitor K, Ca, Magnesium, Na, PTT, PT, platelets, glucose, ABG, CK, o ECG, VS Types of Anesthesia: Regional Anesthesia  Loss of sensory nerve impulses; motor function may or may not be affected o No loss of consciousness  Field Block: “caine” injected around a nerve or group of nerves (dental procedures) o May be combined with epinephrine to prolong o Approximately 30 min to 2 hours  Nerve Block  Intravenous (Bier Block)  Spinal Anesthesia  Epidural Anesthesia Spinal Anesthesia (Subarachnoid Block)

Anesthesia: tip of xiphoid to toes (-caine) injected into cerebrospinal fluid (approx. L 3-5) subarachnoid space Risks: o Loss of vasomotor tone o “Spinal Headache” o Infection o Rising anesthesia above diaphragm  Nursing post operatively: o Keep patient flat o Monitor vital signs o Offer fluids when appropriate Regional Anesthesia: Epidural  Injected into epidural space rather than subarachnoid fluid (usually safer)  Used for OR & OB  Epidural catheter can be left in place for postop pain management (PCA) Regional Anesthetic Risks  Anaphylaxis (ALLERGY)  Incorrect administration technique  Systemic absorption of medication  Infection Conscious Sedation  Reduce intensity of pain without loss of defensive reflexes  Usually a combination of opioid analgesic and sedative-hypnotics  May be administered by credentialed RN  Expect client to be sleepy but arousable  Just because the patient’s eyes are closed doesn’t mean he/she is asleep! Local Anesthesia Local/Topical  Interrupts transmission of sensory nerve impulses so it: numbs what it touches  Requires multiple injections with “CAINE” drug (Example: novacaine, lidocaine)  Duration = 1 min to 20-30 min o -Can be prolonged with added epinephrine  Assess for ALLERGY Latex Allergy/Sensitivity: At Risk:  Genetic predisposition  Children with spina bifida  Urogenital abnormalities  Spinal cord injuries  History of multiple surgeries  Health care professionals Latex Allergy/Sensitivity: Signs and Symptoms  Urticaria  Rhinorrhea  Bronchospasm  Compromised respiratory status  Circulatory collapse & Death Management  Identify those at risk  Latex free environment  Latex free equipment Peri-Operative Standards of Care   

All Policy & Procedures of the medical and surgical nursing division will be followed. Patients shall ALWAYS wear a legible identification band Operative permit(s) must be signed and witnessed according to hospital policy, The procedure documented on the operative permit MUST MATCH what is scheduled on the OR schedule The history and physical shall be completed according to policy and be part of the medical record prior to surgery All ordered lab work shall be collected and results placed in the medical record in accordance with the physician’s orders Dentures, hairpins, jewelry, wigs, contact lenses, nail polish, make-up and prosthesis shall be removed as requested by the physician Any jewelry not removed shall be secured with tape and documented as such Pre-operative skin prep shall be done without abrading, cutting or irritating the patient’s skin Patient privacy shall be provided at all times Any pre-operative drainage tubes shall be placed without tissue trauma and be completed utilizing sterile techniques when indicated All IV infusions shall be monitored to maintain the appropriate flow rate and type of solution and remain patent without signs of inflammation or swelling The patient shall be provided emotional and educational support to reduce pre-operative anxiety The patients shall be provided a safe and normothermic environment in the pre-op waiting area The patient shall be transferred safely to the OR table and safety straps appropriately applied Surgical Expected Outcomes:  Demonstrate knowledge of physiologic & psychological responses to surgical intervention  Absence of infection  Maintenance of skin integrity  Freedom from injury related to positioning, equipment  Maintenance of fluid and electrolyte balance  Satisfaction with pain relief  Participation in the rehab process Postoperative care  Immediate Recovery in Post Anesthesia Care Unit (PACU) o Hand off report o Nurse to Nurse o Anesthesiologist  Nursing care o Protecting patient o Preventing complications while the body is repaired o Uses recovery scoring system Postoperative Nursing Care: Immediate postoperative period  Initial Assessment o Airway patency o Effectiveness of respiration o Presence of artificial airways o Mechanical ventilation, or supplemental oxygen o Circulatory status, vital signs o Wound condition, including dressings and drains o Fluid balance, including IV fluids, output from catheters and drains and ability to void o Level of consciousness and pain Postoperative Nursing Care: Later postoperative period Ongoing Assessment  Respiratory function  General condition

 Vital signs  Cardiovascular function  Fluid status  Pain level  Bowel and urinary elimination  Dressings, tubes, drains, and IV lines Postoperative Nursing Care: Nursing Diagnosis  Ineffective airway clearance- increased secretions 2 to anesthesia, ineffective cough, pain  Ineffective breathing pattern- anesthetic and drug effects, incisional pain  Acute pain  Urinary retention  Risk for infection Admission to Clinical Unit Consider  Anesthesia  Procedure  Blood loss (EBL)  Positioning  Stress response  Risk factors  Initiate postoperative orders  Maintain patient safety  Prevent complications while body recovers and repairs itself  Promote independence Interventions  Careful assessment  Most effective intervention to decrease complications is early ambulation o Out of bed (OOB) within 24 hours o Assist in recovery o Increase muscle tone o Improves GI and GU function o Stimulates circulation and normal respiratory function o Bed exercises o Assertive approach Interventions: Assessment  Respiratory o O2 to maintain sats. > 90% o Wean off postop. day (POD) 1  Cardiovascular o Assessment for circulatory status, BP, heart rate and rhythm o Antithrombotic interventions  Musculoskeletal o Activity o Positioning  Temperature control o Initially hypothermia  Neurological o Quiet environment o Frequent arousing and repetition  Integument

Surgical site-dressings  Dry, intact  Change as ordered o Drains  Check for patency, working properly, output  Check for redness from positioning  Binders for obese Interventions: Assessment  Gastrointestinal o Monitor for NV o After gag reflex o Start ice and water to clear liquids to regular o DAT advance by nurse  Renal o Bladder distension o Minimal output o Void 6-8 hours o Minimum 200 mL  Fluid and Electrolyte Changes o Increase in cortisol and ACTH  Elevated 2-4 days  Trauma increases ADH o Elevated for 12 – 24 hrs  Third spacing possible even with hypovolemia o May reverse in 2-4 days  I&O, resp. and CV assessment Postoperative Phase: Complications  Respiratory- atelectasis, pulmonary embolus  Cardiovascular- venous thrombosis  Gastrointestinal-Hiccoughs, N/V, abdominal distention, paralytic ileus, stress ulcer  GU- urinary retention  Hemorrhage-slipping of a ligature(suture)  Wound infection  Wound dehiscence and evisceration Post-Surgical Infection Postoperative Phase: Complications Dehiscence  Partial or complete separation of the outer layer of the wound.  Possible causes: o Poor suturing technique o Distention o Excessive vomiting o Excessive coughing o Dehydration o Infection Evisceration  Total separation of the layers & protrusion of internal organs or viscera through the open wound.  Causes: same as dehiscence  Treatment: o Call for help o

o Cover with sterile NS soaked gauze/towels o Keep moist o DO NOT ATTEMPTS TO REINSERT ORGANS. o Keep in supine position with knees/hips bent o Assessment/VS q 5 min. until MD arrive o Prepare for surgery. Drainage Systems Postoperative Nursing Care: Gerontological Considerations  Mental status- attributed to medications, pain, anxiety, depression.  Delirium- infection, malignancy, trauma, MI, CHF, opioid use.  Dementia-sundowning-sleep disturbances, lack of structure in the afternoon or early morning, sleep apnea. Common Post-Operative Complications  Pain  Hypovolemic Shock  Thrombophlebitis-DVT  Pulmonary embolus  Fluid Overload  Atelectasis  Pneumonia  Airway Obstruction  Surgical site infection (SSI) Interventions to Prevent Respiratory Complications  Monitoring vital signs  Implementing deep breathing  Coughing  Incentive spirometry  Turning in bed; OOB to chair  Ambulating  Maintaining hydration  Avoiding positioning that decreases ventilation  Monitoring responses to narcotic analgesics Interventions to Prevent Deep Vein Thrombosis (DVT)  OOB to chair early and often  While on bed rest: Dorsiflex, change position frequently, rotate ankles  TED hose  Intermittent Compression boots  Prophylactic SC heparin BID Ambulatory Surgery Discharge criteria  Order written  Airway  Pain  Activity  GI/GU stable  Safety Discharge teaching  Written instructions  To patient and family  Resources  No legal decisions for 24 hours (general)  Has adult supervision for 24 hrs.  When and whom to call if problems

 Keep follow-up appointment Discharge Teaching  Activity  Wound care  Medications  Dietary changes  Symptoms to report  Follow-up care  Individual concerns  Include family  Needs some help...