Perioperative Nursing Care Dr Abdulmonim batiha 1 Perianesthesia
Perioperative Nursing Care Dr. Abdul-monim batiha 1
Perianesthesia and Perioperative Nursing is the field of nursing that addresses the nursing roles associated with the three phases of surgical experiences : pre operative postoperative and intraoperative 2
Preoperative Nursing Care: • begins when the decision to proceed with surgical intervention is made and end with the transfer of patient to the operation table 3
Pre-Operative Responsibilities of Operating Room Nurse: • Patient Assessment • Physical Problems • Emotional Aspects • Understanding of surgery/consent • Legal requirements for chart completion • Read and interpret lab results • Peri. Operative Teaching
PREOPERATIVE NURSING CONSIDERATIONS • COMPLETE PHYSICAL ASSESSMENT – Physical & psychological needs – Medical & surgical history – Completion of required documents • DETERMINE READINESS & MODE OF TRANSPORTATION TO OR • ACCESS HEALTH CARE TEAM AVAILABILITY – – – Surgeon Anesthesia personnel Circulating nurse Scrub person Other personnel
PRE-OP MEDS • Pharmacologic preparation as necessary & psychological support • Facilitates induction of anesthesia & reduces anesthetic requirement • Determinants of drug choice – – – Age Weight Level of anxiety Drug allergies Inpatient/outpatient Timing of administration • Patient & family will need psychological support. • When will the meds be at their peak (timing of administration)
Examples of nursing activities in the preoperative phase include : Pre admission testing • • Initial preoperative assessment Initiate teaching appropriate to patients needs Involve family in interview Verify completion of preoperative testing 7
Admission to surgical unite or center • Complete the preoperative assessment • Assess for risk of complications • Report upnormal findings • Verify that informed consent obtained • Answers family questions • Develop a plan of care 8
Others also in the holding area prior to the surgery • • • Review patient chart Identify patient Verify surgical site Establish intravenous line eg canula Administer prescribed medications Provide support 9
Intra-Operative • • Provide for quiet environment during induction Assist during intubation Observe aseptic technique Safe operation of equipment (lasers, electrosurgery unit) Position patient safely - CV, nervous, respiratory system Document events, patient care given, Provide all supplies, equipment, to team during surgery Provide for a safe transfer to recovery room
• Even turn lights down & be quiet during induction (person going under). • Make sure everything is available (assist during intubation) • Position: know patient history… if they have heart problems, need to make sure patient is positioned safely. Very easy to dislocate joints or break bones while someone is “under”. • Every needle & sponge & supply must be counted before surgery is over! 11
Intraoperative Nursing Care • Begins when patient is transferred to onto the operation table and ends with admission to the post anesthesia care unite Main nursing activities include • Maintain safety • Maintain aseptic environment • Transfer patient to operation room or table • Position the patient in correct alignment • Ensure that instruments count are correct • Complete documentation 12
Physiologic monitoring • Calculate fluid loss or gain • Distinguish normal and abnormal data • Report changes in vital sign Physiologic support • Provide emotional support 13
Postoperative Nursing Care • Begins when patient is admitted to the post anesthesia care unite and end with follow up evaluation in home or clinical setting Activities include • • • Maintain airway Monitor vital sign Assess the effect of anesthetic agents Assess complications assess pain Promote recovery and initiate teaching Initiate discharge plan 14
Surgical classification ( according to urgency) Classification Emergent – patient requires immediate attention, life threatening condition. Indication for Surgery Examples - severe bleeding Without delay - gunshot/ stab wounds - Fractured skull Urgent / Imperative – patient requires prompt attention. Required – patient Within 24 to 30 hours - kidney / ureteral stones Plan within a few weeks or months - cataract Elective – patient should have surgery. Failure to have surgery not catastrophic - repair of scar Optional – patient’s decision. Personal preference needs to have surgery. . - thyroid d/o - vaginal repair - cosmetic surgery
Preparation for Surgery Informed Consent • process for getting permission before conducting a healthcare intervention on a person. A health care provider may ask a patient Which procedures need informed consent ? • Invasive procedure such as need anesthesia • Non surgical procedure that carry considerable risk such as arteriography • Procedures that involve radiation 16
Criteria for valid informed consent • Voluntary • Must be written • Patient must be competent and able to comprehend • In case of incompetent patient family member or law representatives may give consent • Should contain explanation of procedure • Instruction that patient can withdraw consent • Explanation that all patients questions would be answered and if there is any significant notes such as change in customary procedure 17
Assessment of health factor that affect patient preoperatively • Nutritional and fluid status • Drug and alcohol abuse • Respiratory status • Cardiovascular status • Hepatic and renal function • Endocrine function • Immune function • Previous medication use • Psychosocial factors • Spiritual and cultural beliefs 18
Special situations • Ambulatory surgery : patient discharge the same day of surgery • Obese patient • Emergency surgery 19
Preoperative nursing intervention • Preoperative teaching • Deep breathing coughing exercise • Teach patient how to promote mobility and active body movement by frequent position • Leg exercise • Getting out of bed • Pain management • Coping strategies • Reduce anxiety and fear 20
• • Maintain patient safety Manage fluid status Prepare the bowel Prepare the skin 21
Immediate preoperative nursing interventions • Administer pre anesthetic medications • Maintain preoperative records • Transport patient to the operation room 22
Patients @ High risk for Complications • Smokers • Obese • Chronic Lung Diseases • Elderly • HTN • Thoracic or Abdominal Surgeries • Immobilizing Surgery • UTI • Diabetes • Poor Nutritional Status • Dehydration • Heart Disease • Self-fulfilling Prophecy • Inhalant Anesthesia
• Smokers: how many packs a day X how many years they have been smoking • Elderly (and very young as well) • Immobilizing: risk for DVT (use compression devices) • Self fulfilling prophecy: if pt says they are very scared of the surgery, as an RN that needs to be explored further… is there a family history of malignent hyperthermia? pretreatment w/ Dantrium or rapidly treat patient… w/out treatment pt will die! 24
PREVENTING COMPLICATIONS DVT, UTI, Aspiration, Wound Infection, Shock, Constipation • • • Identify those @ risk Provide adequate hydration/nutrition NPO after MN Leg exercises Breathing exercises and IS = incinitive spirometry I&O – Homan’s Sign: only 5 to 10% of positive Homan’s sign means DVT
Incentive Spirometer 26
27
Preventing Complications… • • • Splint Incision to cough Anticoagulant Therapy - Heparin Ambulate and OOB to BRP - ASAP Discourage smoking Fluid and fiber ASAP, laxatives. Enemas Clean Hands Instruct in proper wound care Sterile bowel prep and skin prep Sleep/Rest
PREPPING THE PATIENT TEACHING • Name and purpose of the surgery • NPO after MN and why early awakening, shower, remove all jewelry, makeup, etc • Anesthesia, Cold Room, Smells, Drowsy Feeling • Recovery Room • Post-op care - TCDB, leg exercises, pain management, DVT< OOB ASAP • Begin discharge planning
WAYS TO DECREASE ANXIETY COMMUNICATION • • • Early teaching and counseling Diversional activities Encourage family support Encourage verbalization of fears/loss of control Deep breathing, medications, imagery, music
Ways to Decrease Anxiety… • Spiritual support (communion, Quran, bible reading, prayers, rituals, chants) • Inform family where to wait, buy food, bathroom, phone, overnight and visiting policy • Possible use of sedative or tranquilizer or PRN medications • Dolls/favorite toy for children
NURSING ASSESSMENT • Assessment Data Base - vital signs, weight, height • Review of Systems • Past history of illnesses (i. e. HTN, pneumonia) that may predispose client to complications • Past experience with hospitalization or surgery • Allergies to medications or foods, tapes, surgical scrubs
Nursing Assessment… • Intellectual ability to understand teaching • Language differences, social, spiritual or cultural considerations, anxiety level • Labs: CBC; U/A; Chemistry (electrolytes: K, CL, NA, CA, BS, BUN, Creatine), total bilirubin, albumin, alkaline phosphatase, SGOT, HCO 3, HIV, Pregnancy • Other: Chest X-Ray, EKG if > 40 years old
34
35
PRE-OP NURSING DIAGNOSES • Knowledge Deficit R/T Unfamiliar Planned or Unplanned Surgery • Ineffective individual or family coping R/T Unfamiliar Planned or Unplanned Surgery • Anticipatory Grieving R/T Potential for Loss of Life or Body Part
NURSING RESPONSIBLITIES • Informed Consent Form/Patient Advocacy: make sure patient really does understand what is going to happen. • Secure personal belongings: Dentures, glasses, rings, money(try to give to the family… hosp doesn’t want to be responsible) • Administration of pre-op medications on call to OR - i. e. Demerol, Valium, Atropine • Complete Pre-op Checklist @ clinical site - remove hair pins, loose teeth, dentures, nail polish, bath, urinate, NPO, VS taken within 15 minutes of going to OR, Ted Hose or compression devices
38
39
NURSING RESPONSIBLITIES. . . • Report anything of note that needs to be brought to the attention of the anesthesiologist, surgeon, or OR nurse • • • low potassium, Low potassium can cause cardiac arrythemias. fever, arrthymias, loose teeth, chest pain, or anything unusual • Assure patient has ID bracelet on; Send current chart and any old medical records with the patient; • EVALUATE patients level of understanding, physical stability, emotionally prepared, fulfilled hospital pre-op policies
TYPES OF SURGERY • MAJOR -- Present a real threat to life • MINOR -- Present little threat to life NOTE: **** All patients consider their surgery a major thing ****
Catastrophic Events in the OR Anticipated: Anticipated • Cardiac Arrest in an unstable patient • Massive Blood Loss - during trauma surgery • Loss of ability to ventilate a patient
Catastrophic Events in OR. . . Unanticipated: • Latex Allergy Reaction - reactions can range from urticaria to anaphylaxis • Maligant Hyperthermia - rare, life-threatening disorder that can be triggered by anesthesia drugs - Is an autosomal dominant trait
Peri-Operative Standards of Care (example) • 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
Peri-Operative Standards of Care (example) • 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 45
Peri-Operative Standards of Care … • 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
Peri-Operative Standards of Care … • 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
Expected Outcomes: • Demonstrate knowledge of physiologic & psychological responses to surgical intervention • Absence of infection • Maintenance of skin integrity • Freedom from injury R/T positioning, equipment • Maintenance of fluid and electrolyte balance • Satisfaction with pain relief • Participation in the rehab process
Purposes of informed consent 49
50
51
52
53
54
55
56
57
58
59
60
61
- Slides: 61