TimbySmith Introductory MedicalSurgical Nursing 11e Chapter 14 Perioperative

Perioperative Care • Surgery: causes stress and risks for complications – Variables affecting surgery • Procedure performed, age, and coexisting medical conditions – Types of surgery: Table 14 -1 – Inpatient and outpatient surgery • Ambulatory surgery: increasing due to advanced surgical techniques and anesthesia, reimbursement, managed care, changes in Medicare Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Perioperative Care—(cont. ) • Nursing goals – Minimize clients’ anxiety – Prepare for surgery – Monitor for complications during surgery – Assist in uncomplicated recovery • Three phases: preoperative, intraoperative, postoperative Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Preoperative Care • Nursing assessment – Reviews preoperative instructions; diet, skin prep – Identifies risks related to age, nutritional status, alcohol or tobacco use, physical condition – Performs history and physical examination – Assess clients’ understanding of surgery – Consider cultural needs; beliefs, disposal of body parts, blood transfusions Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Preoperative Care—(cont. ) • Surgical consent – Required for invasive procedures that require anesthesia and risks of complications – Criteria for valid informed consent: voluntary, incompetent client • Minor clients: signed by parent or guardian – Must sign before receiving preoperative sedatives, adult witness – Nurse is responsible to have signed consent on client’s chart Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Preoperative Teaching • Preoperative medications, postoperative pain control • Description of postanesthesia area • Discuss frequency of vital signs/monitoring equipment • Explains and demonstrates deep-breathing and coughing, incentive spirometry, splints, leg and feet exercises • Inform of IV fluids, other lines, and tubes • Express anxieties and fears • Include family members in preoperative explanations Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Gerontologic Considerations • Diminished abilities to hear, see, and understand may interfere with preoperative/postoperative teaching. • Nurses need to repeat explanations and demonstrations. • Include family members • Awareness of cognitive changes due to pain, medications, or change in environment • Teach back technique to help understand needs to be clarified Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Preoperative Care—(cont. ) • Physical preparation – Skin preparation; germicide soap, hair removal – Elimination: inserts indwelling catheter, enemas, and laxatives – Foods and fluids: NPO or clear liquids, adequate intake of protein and ascorbic acid; wound healing – Care of valuables – Attire/grooming: makeup and nail polish removed; antiembolism stockings – Prosthesis: dentures, artificial limbs Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Preoperative Care—(cont. ) • Preoperative medications – Types: anticholinergics, histamine 2 -receptor antagonists, opioids, sedatives, tranquilizers – See Drug Therapy Table 14 -1 – Safety: identification bracelet, drug allergies, vital signs, asks client to void, surgical consent is signed – Instructions: remains in bed, side rails, call button Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Preoperative Care—(cont. ) • Psychosocial preparation – Preoperative teaching and listening can help allay fears and anxieties. – Assess coping methods; religious sources; clergy or chaplain – Preoperative checklist • Nurse’s roles: assessment, preoperative medications, IV, preoperative preparations • Emphasis on right procedure at the right site Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question A surgery which the client will not be harmed if the surgery is not performed but will benefit if it is performed is called: A) Emergency surgery B) Urgent surgery C) Elective surgery D) Required surgery Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer C) Elective surgery Rationale: Elective surgeries such as revision of scars and vaginal repairs are examples of elective surgeries. The client’s condition would not be harmed if surgery was not performed immediately, but the surgery may benefit the client if it is performed. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Process for Preoperative Care • Assessment: physical and psychological status • Diagnosis, Planning, and Interventions – Anxiety: ask about concerns, maintain contact with client – Knowledge Deficit: assess level of knowledge, use visual aids, include family members • Evaluation of Expected Outcomes – Client minimal anxiety, demonstrates knowledge Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Intraoperative Care • Anesthesia – Types • General: loss of sensation, reflexes, and consciousness; four stages; endotracheal tube • Regional: loss of sensation and decreased mobility to specific anesthetized area; risk for injury and burns • Procedural sedation: conscious sedation; side effects: respiratory depression; antagonists Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Surgical Team • Anesthesiologist/anesthetist • Surgeon • Surgical assistants – First, second, and third assistants • Intraoperative nurses – Scrub nurse and circulating nurse Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Operating Room Environment • Authorized OR personnel or surgical clients • Air filtered and positive pressure: reduce infection • Temperature is below 70° F • Surgical attire: decreases microbial growth • Three designated zones – Unrestricted zone – Semirestricted zone – Restricted zone Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Management • Surgical asepsis: strict protocols to protect client from infection • Intraoperative assessment – BP and pulse and respiratory rates – Level of consciousness – General physical condition – Presence of catheters and tubes – Review of client’s medical record Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Prevention of Intraoperative Complications • Infection: strict aseptic technique, risk for retention of foreign objects in wound • Fluid volume excess or deficit: recording IV fluids, urine output • Injury related to positioning: prolonged pressure, nerve injury • Hypothermia: low temps in OR, cold IV fluids, inhalation of cool gases, exposure of body surfaces, open wounds, prolonged activity – Malignant hyperthermia Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Process: Procedural Sedation • Assessment: vital signs, level of consciousness, dysrhythmias, signs of distress • Diagnosis, Planning, and Interventions – Risk for ineffective breathing pattern: semi-Fowler’s position, distress due to head position, deep breathing and coughing – Risk for perioperative injury: fall prevention, assist with ambulation, monitor LOC • Evaluation of Expected Outcomes: patent airway and effective breathing pattern; no injury Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question A client undergoing surgery is at risk for injury related to sedation. To keep the client safe and free of injury, the nurse will: A) Position the client in an upright or semi-Fowler’s position B) Assist the client with ambulation and carefully monitor all activities C) Observe for signs of respiratory distress D) Encourage client to take deep breaths and cough at least every hour Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer B) Assist the client with ambulation and carefully monitor all activities Rationale: Clients recovering from sedation may have impaired judgment and reflexes; the nurse may protect them from injury. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Postoperative Care • Immediate postoperative nursing management – Maintaining an intact surgical site – Observing for vascular changes – Keeping the client warm – Positioning of client: protect incision and drains – Assessing for orthostatic hypotension Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Postoperative Care—(cont. ) • Initial postoperative nursing management – Airway patency, effective respirations, artificial airways, mechanical ventilation, oxygen – Circulatory status; wound condition, dressing, and drains – Fluid balance: IV fluids, catheter and drain output – Level of consciousness and pain – Aldrete scale Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Prevention of Postoperative Complications Nursing Management • Hemorrhage: assess for S/S of shock, inspect dressings, blood transfusions, reinforce dressings, wound drains • Shock: fluid and electrolyte loss, trauma, anesthetics, medications; assess for shock • Hypoxia: oxygen and suction equipment available; assess for signs of cyanosis and dyspnea • Aspiration: suction equipment at bedside; assess for difficulty swallowing, side-lying position Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Postoperative Care—(cont. ) • Later postoperative nursing management – Fluids and nutrition: IV fluids, dietary progression; assess for nausea and vomiting, nasogastric tube • Nursing guidelines for resuming oral fluids • NPO/assess bowel sounds • Assess swallowing/sips of water/ice chips • Administer antiemetic medications Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question Which intervention would be indicated for a client with thrombophlebitis of the leg? A) Encourage fluids by mouth. B) Gently massage the affected leg. C) Keep the leg positioned below the level of the heart. D) Start antibiotic therapy. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer A) Encourage fluids by mouth. Rationale: Efforts should be made to ensure that clients are adequately hydrated. Dehydration and/or fluid volume deficit increase the viscosity of the blood. Increased viscosity is a causative factor in the development of thrombophlebitis. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Postoperative Care—(cont. ) • Skin integrity/wound healing: wound assessment – Wound devices: Penrose, Jackson-Pratt, Hemovac • Phases of wound healing – Three modes of wound healing • Primary intention • Secondary intention • Tertiary intention Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Postoperative Care—(cont. ) • Skin integrity/wound healing: nursing management − Factors affecting healing: impaired circulation, malnutrition; hyperglycemia, infection, foreign bodies, age, immobility – Signs of wound infection: increased incisional pain, redness, swelling, heat around incision, purulent drainage, fever, headache, anorexia – Antibiotics – Adequate nutrition; controlling glucose levels – Complications: dehiscence, evisceration Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Postoperative Care—(cont. ) • Activity: advance activity as tolerated, regional anesthesia—initially restricted – Spinal headache: remain lying flat for longer period of time • Bowel elimination – Abdominal distention: causes, encourage to ambulate, frequent position changes, diet advancement – Paralytic ileus, acute gastric dilatation Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Postoperative Care—(cont. ) • Urinary elimination: indwelling catheter; monitor urine output – Bladder distention; restlessness, lower abdominal discomfort, fluid intake with urinary output • Psychosocial status: changes in body image, lifestyle – Referrals for counseling, support groups Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Client and Family Teaching and Discharge • Discharge instructions verbal and in writing • Evaluation – Supervised home care – Supplies – Special dietary needs – Adjustments to living environment – Pain medications Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins