Interventions for Preoperative Clients Perioperative Nursing Definition of

Interventions for Preoperative Clients

Perioperative Nursing Definition of Surgery is any procedure performed on the human body that uses instruments to alter tissue or organ integrity

Purposes of Surgery Diagnostic ¢ Curative ¢ Restorative ¢ Palliative surgery, which makes the client more comfortable ¢ Cosmetic surgery, which reconstructs the skin and underlying structures ¢

Perioperative Nursing Types of Surgery ¢ Degree of urgency – necessity to preserve the client’s life, body part, or body function.

Perioperative Nursing Types of Surgery (Urgency) Emergency- performed immediately to preserve function or the life of the client. ¢ Elective – is performed when surgical intervention is the preferred treatment for a condition that is not imminently life threatening or to improve the client’s life. ¢ Urgent – Necessary for client’ health to prevent additional problem from developing; not necessarily an emergency. ¢ Required – has to be performed at some point; can be pre-scheduled. ¢

Perioperative Nursing Types of Surgery (Degree of risk) ¢ Degree of risk – involved in surgical procedure is affected by the client’s age, general health, nutritional status, use of medications, and mental status.

Perioperative Nursing Type of Surgery (Degree of Risk) ¢ ¢ ¢ ¢ Major – involves a high degree of risk. Minor – normally involves little risk. Age – very young and elder clients are greater surgical risks than children and adult. General health surgery is least risky when the client’s general health is good. Nutritional Status – required for normal tissue repair. Medications – regular use of certain medications can increase surgical risk. Mental status – disorder that affect cognitive function

¢ Extent of surgery – Simple and radical

Perioperative Nursing Surgical settings Surgical suites ¢ Ambulatory care setting ¢ Clinics ¢ Physician offices ¢ Community setting ¢ Homes ¢

Perioperative Nursing Surgical settings Disadvantages of outpatient Less time for rapport Less time to assess, evaluation, teach Risk of potential complication post D/C. ¢ Advantages of outpatient: outpatient Low cost Low risk of infection Less interruption of routine Less than from work Less stress ¢

Collaborative Management Assessment ¢ History and data collection Age l Drugs and substance use l Medical history, including cardiac and pulmonary histories l Previous surgery and anesthesia l Blood donations l Discharge planning l

Physical Assessment/Clinical Manifestations Obtain baseline vital signs. ¢ Focus on problem areas identified by the client’s history on all body systems affected by the surgical procedure. ¢ Report any abnormal assessment findings to the surgeon and to anesthesiology personnel. ¢

System Assessment Cardiovascular system ¢ Respiratory system ¢ Renal/urinary system ¢ Neurologic system ¢ Musculoskeletal system ¢ Nutritional status ¢ Psychosocial assessment ¢ Gerontological Considerations ¢

Preoperative Nursing Care Psychosocial considerations Level of anxiety ¢ Coping ability ¢ Support systems ¢

Preoperative Nursing Care Gerontological Considerations ¢ Cardiovascular Coronary flow decreases Heart rate decreases Response to stress decreases Peripheral vascular decreases Cardiac output decreases Cardiac reserve decreases

Preoperative Nursing Care Gerontological Considerations Respiratory System Static lung volumes decreases Pulmonary static recoil decreases Sensitivity of the airway receptors decreases ¢ Nervous system Increased incidence of post. op. confusion. Increased incidence of delirium Increased sensitivity to anesthetic agents ¢

Preoperative Nursing Care Gerontological Considerations ¢ Renal System Renal blood flow declines 1. 5% per year. Renal clearance reduced ¢ Gastrointestinal Decreased intestinal motility Decreased liver blood flow Delayed gastric emptying

Preoperative Nursing Care Gerontological Considerations Musculoskeletal Decreased mass, tone, strength Decreased bone density ¢ Integumentary Decreased elasticity Decreased lean body mass Decreased subcutaneous fat ¢

Laboratory Assessment Urinalysis ¢ Blood type and crossmatch ¢ Complete blood count or hemoglobin level and hematocrit ¢ Clotting studies ¢ Electrolyte levels ¢ Serum creatinine level ¢ Pregnancy test ¢ Chest x-ray examination ¢ Electrocardiogram ¢

Preoperative Nursing Consent Nature and intention of the surgery ¢ Name and qualifications of the person performing the surgery. ¢ Risks, including tissue damage, disfigurement, or even death ¢ Chances of success ¢ Possible alternative measures ¢ The right of the client to refuse consent or later withdraw consent. ¢

Deficient Knowledge Interventions ¢ Informed consent The surgeon is responsible for obtaining signed consent before sedation is given and surgery is performed. l The nurse’s role is to clarify facts presented by the physician and dispel myths that the client or family may have about surgery. l

Implementing Dietary Restrictions Client is given nothing by mouth (NPO) for 6 to 8 hours before surgery. ¢ NPO status decreases the risk for aspiration. ¢ Failure to adhere can result in cancellation of surgery or increase the risk for aspiration during or after surgery. ¢

Administering Regularly Scheduled Medications ¢ Consult the medical physician and anesthesia provider for instructions about drugs, such as those taken for diabetes, cardiac disease, glaucoma, regularly scheduled anticonvulsants, antihypertensives, anticoagulants, antidepressants, or corticosteroids.

Intestinal Preparation Bowel or intestinal preparations are performed to prevent injury to the colon and to reduce the number of intestinal bacteria. ¢ Enema or laxative may be ordered by the physician. ¢

Skin Preparation The skin is the body’s first line of defense against infection; a break in the barrier increases the risk for infection. ¢ Shower using antiseptic solution. ¢ Shaving as a procedure before surgery is viewed as controversial. ¢

Preparing the Client Possible placement of tubes, drains, and vascular access devices ¢ Teaching about postoperative procedures and exercises: ¢ l Breathing exercises, incentive spirometry, coughing and splinting (Continued)

Preparing the Client (Continued) l Leg procedures and exercises, antiembolism stockings and elastic wraps, early ambulation, and rangeof-motion exercises

Anxiety Interventions Preoperative teaching ¢ Encouraging communication ¢ Promoting rest ¢ Using distraction ¢ Teaching family and significant others ¢

Preoperative Nursing Care Anxiety The nurse must consider the pt’s family and friends when planning psychological support. ¢ Empowering their sense of control. Activities that decreasing anxiety are deep breathing, relaxation exercises, music therapy, massage and animal-assisted therapy. ¢ Use of medication to relieve anxiety. ¢

Preoperative Chart Review Ensure all documentation, preoperative procedures, and orders are complete. ¢ Check the surgical consent form and others for completeness. ¢ Document allergies. ¢ Document height and weight. ¢ (Continued)

Preoperative Chart Review (Continued) Ensure results of all laboratory and diagnostic tests are on the chart. ¢ Document and report any abnormal results. ¢ Report special needs and concerns. ¢

Preop Client Prep Client should remove most clothing and wear a hospital gown. ¢ Valuables should remain with family member or be locked up. ¢ Tape rings in place if they can’t be removed. ¢ Remove all pierced jewelry. ¢ (Continued)

Preop Client Prep (Continued) Client wears an identification band. ¢ Dentures, prosthetic devices, hearing aids, contact lenses, fingernail polish, and artificial nails must be removed. ¢

Preoperative Medication Reduce anxiety. ¢ Promote relaxation. ¢ Reduce pharyngeal secretions. ¢ Prevent laryngospasm. ¢ Inhibit gastric secretion. ¢ Decrease amount of anesthetic needed for induction and maintenance of anesthesia. ¢

Preoperative Nursing Care Medications Sedatives/hypnotics- Nembutal ¢ Tranquilizers-Ativan, versed, valium ¢ Opiate analgesics- Demerol, morphine ¢ Anticholinergics-Atropine sulfate, atarax ¢ H 2 o blockers. - Tagamet, Zantac ¢ Antiemetic- Reglan, Phenergan ¢

Preoperative Nursing Care Preanesthesia Management Physical Status Categories ASA 1: Healthy patient with no disease ¢ ASA 11: Mild systemic ds without fx limitations ¢ ASA 111: Severe systemic ds associated with definite fx limitations ¢ ASA 1 V: Severe systemic ds that is a constant threat to life. ¢ ASA V: Moribund pt. Who is not expected to survive without the operation. ¢ ASA V 1: A declared brain-death whose organ are being recovered for donor. ¢

Members of the Surgical Team Surgeon ¢ Surgical assistant ¢ Anesthesiologist ¢ Certified registered nurse anesthetist ¢ Holding area nurse ¢ Circulating nurse ¢ Scrub nurse ¢ Surgical technologist ¢ Operating room technician ¢

Perioperative Nursing Care Surgical team 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

Environment of the Operating Room Preparation of the surgical suite and team safety ¢ Layout ¢ Health and hygiene of the surgical team ¢ Surgical attire ¢ Surgical scrub ¢

Intraoperative Nursing Care Surgical asepsis ¢ Ensure sterility ¢ Alert for breaks

Intraoperative Phase Anesthesia ¢ Greek word- anesthesis, meaning “negative sensation. ” Artificially induced state of partial or total loss of sensation, occurring with or without consciousness. Blocks transmission of nerve impulses Suppress reflexes Promotes muscle relaxation Controlled level of unconsciousness

Anesthesia Induced state of partial or total loss of sensation, occurring with or without loss of consciousness ¢ Used to block nerve impulse transmission, suppress reflexes, promote muscle relaxation, and, in some instances, achieve a controlled level of unconsciousness ¢

General Anesthesia Reversible loss of consciousness is induced by inhibiting neuronal impulses in several areas of the central nervous system. ¢ State can be achieved by a single agent or a combination of agents. ¢ Central nervous system is depressed, resulting in analgesia, amnesia, and unconsciousness, with loss of muscle tone and reflexes. ¢

Stages of General Anesthesia Stage 1: analgesia ¢ Stage 2: excitement ¢ Stage 3: operative ¢ Stage 4: danger ¢

Administration of General Anesthesia Inhalation: intake and excretion of anesthetic gas or vapor to the lungs through a mask ¢ Intravenous injection: barbiturates, ketamine, and propofol through the blood ¢ Adjuncts to general anesthetic agents: hypnotics, opioid analgesics, neuromuscular blocking agents ¢

Balanced Anesthesia Combination of intravenous drugs and inhalation agents used to obtain specific effects ¢ Combination used to provide hypnosis, amnesia, analgesia, muscle relaxation, and reduced reflexes with minimal disturbance of physiologic function ¢ (Continued)

Balanced Anesthesia (Continued) ¢ Example: thiopental for induction, nitrous oxide for amnesia, morphine for analgesia, and pancuronium for muscle relaxation

Complications from General Anesthesia Malignant hyperthermia: possible treatment with dantrolene ¢ Overdose ¢ Unrecognized hypoventilation ¢ Complications of specific anesthetic agents ¢ Complications of intubation ¢

Local or Regional Anesthesia Sensory nerve impulse transmission from a specific body area or region is briefly disrupted. ¢ Motor function may be affected. ¢ Client remains conscious and able to follow instructions. ¢ Gag and cough reflexes remain intact. ¢ Sedatives, opioid analgesics, or hypnotics are often used as supplements to reduce anxiety. ¢

Local Anesthesia Topical anesthesia ¢ Local infiltration ¢ Regional anesthesia ¢ Field block l Nerve block l Spinal anesthesia l Epidural anesthesia l

Complications of Local or Regional Anesthesia Anaphylaxis ¢ Incorrect delivery technique ¢ Systemic absorption ¢ Overdosage ¢ (Continued)

Complications of Local or Regional Anesthesia (Continued) ¢ Assess for central nervous system stimulation, central nervous system and cardiac depression, restlessness, excitement, incoherent speech, headache, blurred vision, metallic taste, nausea and vomiting, tremors, seizures, increased pulse, respirations, and blood pressure.

Treatment of Complications Establish an open airway. ¢ Give oxygen. ¢ Notify the surgeon. ¢ Fast-acting barbiturate is usual treatment. ¢ If toxic reaction is untreated, unconsciousness, hypotension, apnea, cardiac arrest, and death may result. ¢

Conscious Sedation IV delivery of sedative, hypnotic, and opioid drugs reduces the level of consciousness but allows the client to maintain a patent airway and to respond to verbal commands. ¢ Diazepam, midazolam, meperidine, fentanyl, alfentanil, and morphine sulphate are the most commonly used drugs. ¢ (Continued)

Conscious Sedation (Continued) ¢ Nursing assessment of airway, level of consciousness, oxygen saturation, electrocardiographic status, and vital signs are monitored every 15 to 30 minutes.

Collaborative Management Assessment ¢ Medical record review ¢ Allergies and previous reactions to anesthesia or transfusions ¢ Autologous blood transfusion ¢ Laboratory and diagnostic test results ¢ Medical history and physical examination findings ¢

Risk for Perioperative Positioning Injury Interventions include: ¢ Proper body position ¢ Risk for pressure ulcer formation ¢ Prevention of obstruction of circulation, respiration, and nerve conduction

Impaired Skin Integrity and Impaired Tissue Integrity Interventions include: ¢ Plastic adhesive drape ¢ Skin closures, sutures and staples, nonabsorbable sutures ¢ Insertion of drains ¢ Application of dressing ¢ Transfer of client from the operating room table to a stretcher

Potential for Hypoventilation ¢ Continuous monitoring of: Breathing l Circulation l Cardiac rhythms l Blood pressure and heart rate l ¢ Continuous presence of an anesthesia provider

Interventions for Postoperative Clients

PACU Recovery Room Purpose is to provide ongoing evaluation and stabilization of clients to anticipate, prevent, and treat complications after surgery. ¢ PACU is usually located close to the surgical suite. ¢ The PACU nurse is skilled in the care of clients with multiple medical and surgical problems that can occur following a surgical procedure. ¢

Collaborative Management Assessment ¢ Physical assessment and clinical manifestations ¢ Assess respiration. l Examine surgical area for bleeding l Monitor vital signs. l Assess for readiness to discharge once criteria have been met. l

Respiratory System Airway assessment ¢ Breath sounds ¢ Other respiratory assessments ¢

Cardiovascular Assessment Vital signs ¢ Cardiac monitoring ¢ Peripheral vascular assessment ¢

Neurologic System Cerebral functioning ¢ Motor and sensory assessment important after epidural or spinal anesthesia ¢ Motor function: simple commands; client to move extremities l Return of sympathetic nervous system tone: gradually elevate head and monitor for hypotension l

Fluid, Electrolyte, and Acid. Base Balance Check fluid and electrolyte balance. ¢ Make hydration assessment. ¢ Intravenous fluid intake should be recorded. ¢ Assess acid-base balance. ¢

Renal/Urinary System The effects of drugs, anesthetic agents, or manipulation during surgery can cause urine retention. ¢ Assess for bladder distention. ¢ Consider other sources of output such as sweat, vomitus, or diarrhea stools. ¢ Report a urine output of < 30 m. L/hr. ¢

Gastrointestinal System Nausea and vomiting are common reactions after surgery. ¢ Peristalsis may be delayed because of long anesthesia time, the amount of bowel handling during surgery, and opioid analgesic use. ¢ Clients who have abdominal surgery often have decreased peristalsis for at least 24 hours. ¢

Nasogastric Tube Drainage ¢ Tube may be inserted during surgery to decompress and drain the stomach, to promote gastrointestinal rest, to allow the lower gastrointestinal tract to heal, to provide an enteral feeding route, to monitor any gastric bleeding, and to prevent intestinal obstruction. (Continued)

Nasogastric Tube Drainage (Continued) Assess drained material every 8 hours. ¢ Do not move or irrigate the tube after gastric surgery without an order from the surgeon. ¢

Skin Assessment Normal wound healing ¢ Ineffective wound healing: can be seen most often between the 5 th and 10 th days after surgery ¢ l Dehiscence: a partial or complete separation of the outer wound layers, sometimes described as a “splitting open of the wound. ” (Continued)

Skin Assessment (Continued) l ¢ Evisceration: a total separation of all wound layers and protrusion of internal organs through the open wound. Dressings and drains, including casts and plastic bandages, must be assessed for bleeding or other drainage on admission to the PACU and hourly thereafter.

Postoperative Phase

Discomfort/Pain Assessment Client almost always has pain or discomfort after surgery. ¢ Pain assessment is started by the postanesthesia care unit nurse. ¢ Pain usually reaches its peak the second day after surgery, when the client is more awake, more active, and the anesthetic agents and drugs given during surgery have been excreted. ¢

Impaired Gas Exchange Interventions include: ¢ Airway maintenance ¢ Positioning the client in a side-lying position or turning his or head to the side to prevent aspiration ¢ Encouraging breathing exercises ¢ Encouraging mobilization as soon as possible to help remove secretions and promote lung expansion

Impaired Skin Integrity Interventions include: ¢ Nursing assessment of the surgical area ¢ Dressings: first dressing change usually performed by surgeon ¢ Drains: provide an exit route for air, blood, and bile as well as help prevent deep infections and abscess formation during healing (Continued)

Impaired Skin Integrity (Continued) Drug therapy including antibiotics and irrigations are used to treat wound infection. ¢ Surgical management is required for wound opening. ¢

Acute Pain Interventions include: ¢ Drug therapy ¢ Complementary and alternative therapies such as: Positioning l Massage l Relaxation and diversion techniques l

Potential for Hypoxemia Interventions include: ¢ Maintenance of airway patency and breathing pattern ¢ Prevention of hypothermia ¢ Maintenance of oxygen therapy as prescribed

Health Teaching Prevention of infection ¢ Dressing care ¢ Nutrition ¢ Pain medication management ¢ Progressive increase in activity level ¢ Use of proper body mechanics ¢