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Chapters 16, 17,18

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Perioperative Care:

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-When the patient is scheduled for surgery until the patient's condition stabilizes and patient is d/c from facility. -*Preoperative, intraoperative, and perioperative*

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Perioperative Care refers to the time:

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An educator, advocate, and a promoter of health.

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What 3 things will you, as a nurse, function as to the patient in parioperative process?

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Safety, advocacy, patient education, and a culture of safety.

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The peri operative emphasis on:

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-Provide care for the perioperative client -Provide nursing care for clients experiencing signs and symptoms of commonly occurring complications, shock, and hemorrhage. -Manage the pain of the perioperative client -Develop age-related teaching/learning strategies for the perioperative client.

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Objective to Perioperative Care:

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The patient is scheduled for surgery and ends at the time of transfer to the surgical suite.

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The preoperative period begins when:

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*Description:* Performed to determine the origin and cause of a disorder or the cell type for cancer. *Condition of Surgical Procedure:* breast biopsy, exploratory laparotomy, arthroscopy.

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Reason for Surgery, Diagnostic:

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*Description:* Performed to resolve a health problem by repairing or removing the cause. *Condition of Surgical Procedure:* Cholecystectomy, appendectomy, hysterectomy.

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Reason for Surgery, Curative:

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*Description:* Performed to improve a patient's functional ability. *Condition of Surgical Procedure:* Total knee replacement, finger re-implantation.

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Reason for Surgery, Restorative:

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*Description:* Performed to relieve symptoms of a disease process, but does not cure. *Condition of Surgical Procedure:* Colostomy, nerve root resection, tumor de-bulking, ileostomy.

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Reason for Surgery, Palliative:

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*Description:* Performed primarily to alter or enhance personal appearance. *Condition of Surgical Procedure:* Liposuction, revision of scars, rhinoplasty, blepharoplasty.

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Reason for Surgery, Cosmetic:

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*Description:* Planned for correction of a nonactive problem. *Condition of Surgical Procedure:* Cataract removal, hernia repair, hemorrhoidectomy, total joint replacement.

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Urgency of Surgery, Elective:

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*Description:* Requires prompt intervention; may be life threatening if treatment is delayed more than 24-48hrs. *Condition of Surgical Procedure:* Intestinal obstruction, bladder obstruction, kidney or ureteral stones, bone fracture, eye injury, acute cholecystitis.

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Urgency of Surgery, Urgent:

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*Description:* Requires immediate intervention because of life-threatening consequences. *Condition of Surgical Procedure:* Gunshot or stab wound, severe bleeding, abdominal aortic aneurysm, compound fracture, appendectomy.

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Urgency of Surgery, Emergent:

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*Description:* Procedure without significant risk; often done with local anesthesia. *Condition of Surgical Procedure:* Incision and drainage (I&D), implantation of a venous access device (VAD), muscle biopsy.

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Degree of Risk of Surgery, Minor:

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*Description:* Procedure of greater risk; usually longer and more extensive than a minor procedure. *Condition of Surgical Procedure:* Mitral valve replacement, pancreas transplant, lymph node dissection.

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Degree of Risk of Surgery, Major:

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*Description:* Only the most overtly affected areas involved in the surgery. *Condition of Surgical Procedure:* Simple/partial mastectomy.

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Extent of Surgery, Simple:

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*Description:* Extensive surgery beyond the area obviously involved; is directed at finding a root cause. *Condition of Surgical Procedure:* Radical prostatectomy, radical hysterectomy.

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Extent of Surgery, Radical:

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*Description:* Surgery performed in a body cavity or body area through one or more endoscopes; can correct problems, remove organs, take tissue for biopsy, re-route blood vessels and drainage systems; is a fast-growing and ever-changing type of surgery. *Condition of Surgical Procedure:* Arthroscopy, tubal ligation, hysterectomy, lung lobectomy, coronary artery bypass, cholecystectomy.

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Extent of Surgery, Minimally Invasive Surgery (MIS):

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*Age* (older than 65), *nutritional, health status, fluid and electrolyte imbalances, radiation, cardiopulmonary, chemotherapy, meds* (antihypertensives, tricyclic antidepressants, anticoagulants, NSAIDs), *family history* (malignant hyperthermia, cancer, bleeding disorder), *prior surgical experience* (less than optimal emotional reaction, anesthesia reactions or complications, postoperative complications), *type of surgery* (neck, oral, or facial procedures [airway complications], chest or high abdominal procedures [pulmonary complications], abdominal surgery [paralytic ileus, DVT).

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Risk Factors the Acknowledge In The Preoperative Phase:

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*Medical history* (decreased immunity, diabetes, pulmonary disease, cardiac disease, hemodynamic instability, multisystem disease, coagulation defect or disorder, anemia, dehydration, infection, HTN, hypotension, any chronic disease), *health history* (malnutrition or obesity, drug, tobacco, alcohol, or illicit substance use or abuse, altered coping ability).

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Risk Factors the Acknowledge In The Preoperative Phase Con't:

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-Validates & clarifies information -Assess to identify problems that warrant further patient assessment or intervention before the procedure -Obtains baseline vital signs

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The Preoperative Nurse:

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-History & data collection -Age; discharge planning -Drugs and substance use -Medical history, including cardiac pulmonary histories -Previous surgical procedures & anesthesia; blood donations.

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What types of assessments are done in collaboration?

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past & present: meds, diet, allergies (latex), personal habits, occupation, finances, family support, knowledge of surgery, attitude.

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Preoperative Phase-What Assessment the Nurse Finds:

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-Nursing hx (^). -Physical Exam -Diagnostic Tests: CBC, electrolytes, creatinine, urinalysis, x-ray exams, EKG, blood type, PTT, PT, platelet count; Blood donations; pregnancy test; clotting studies. -Radiographic; CXR; EKG -Bloodless Surgery/Discharge

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Preoperative Phase-Assessment:

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Surgeon is responsible for obtaining the signed consent before sedation and/or surgery. The nurse's role is to clarify facts presented by the physician and dispel myths that the patient or family may have about surgery.

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Preoperative Teaching r/t Informed Consent:

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-Patient must be mentally competent. *If patient just received medications that affect comprehensive neuro status, cannot sign consent.* -If the patient is a minor, a guardian, parent or court order will sign the permit; the state dictates that age.

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To Obtain an Informed Consent:

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-Have the right to have or to initiate advance directives, such as living will or durable power of attorney. -Advance directives provide legal instructions to the health care providers about the patient's wishes and are to be followed. *Surgery does not provide an exception to a patient's advance directives or living will.*

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The Patient Self-Detemination Act allow the patient to:

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Patient will... -Explain the purpose and expected results of the planned surgery. -Ask questions when a term or procedure is not known -Adhere to the NPO requirements -State an understanding of preoperative preparations (e.g., skin preparation, bowel preparation). -Demonstrate correct use of exercises and techniques to be used after surgery for the prevention of complications (e.g., splinting the incision, coughing/deep breathing, performing leg exercises, ambulating as early as permitted).

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Name 5 Expected Outcomes for Deficient Knowledge Nursing Diagnosis:

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-Patient is instructed to not have anything to eat or drink by mouth *6-8hrs* prior to procedure. -NPO decreases aspiration risk. -Patients should be given written and oral instructions to stress adherence -Surgery can be cancelled if NPO 6-8hrs prior to surgery is not followed.

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NPO Guidelines:

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-Medical physicians & anesthesia providers should be consulted for instructions about regularly taken prescription medications prior to surgery. -Drugs for cardiac disease, respiratory disease, seizures, and HTN are commonly allowed with a sip of water before surgery. -Diabetic patient who takes insulin may be given a reduced or modified dose of intermediate- or long-acting insulin based on the blood glucose level or may be given regular (fast-acting) insulin in divided doses on the day of surgery. As an alternative, an IV infusion of 5% dextrose in water may be given with the insulin to prevent low blood sugar during surgery.

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Things to Consider When Administering Regularly Scheduled Medications:

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-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. -Perform skin preparation to decrease the risk of impairment of skin integrity.

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Bowel or Intestinal Preps:

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-Skin prep before surgery is the first step in the prevention of surgical wound infection. -Provide a warm, comfortable, and private environment during the procedure since it can be uncomfortable to the patient. -If pt is at home, he/she may shower with antiseptic solution 2 days before surgery; if in hospital, showering and cleaning are repeated the night before or in the morning before transfer to surgical suite.

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Skin Preparation Considerations:

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-The CDC recommends that if shaving is necessary, the hair should be removed using disposable sterile supplies and aseptic principles immediately before the start of the surgical procedure. -Shaving is now considered an inappropriate hair removal method; only clippers or depilatories are to be used for hair removal.

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Skin Preparation Considerations Con't:

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*Tubes:* Pt may need an indwelling urinary catheter (Foley) before, during, or after surgery. A NG tube may be inserted before abdominal surgery to decompress or empty the stomach and the upper bowel.

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Preparing the Patient for Tubes:

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*Drains:* are often placed during surgery to help remove fluid from the surgical site. Some drains are under the dressing; others are visible and require emptying.

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Preparing the Patient for Drains:

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*Vascular Access:* is placed for patients receiving a general anesthetic and most patients receiving other types of anesthetics. Access is needed to give drugs and fluids before, during, and after surgery. -Patients who are dehydrated or are at risk for dehydration may receive fluids before surgery.

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Preparing the Patient for Vascular Access:

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-Informed consent -Nutrition/fluids-IV; NPO after MN -Elimination-enemas, foley. -Hygiene- skin scrub; remove nail polish, hair pins, hospital gown. -VS; Height/weight -Special orders (insert tubes, medications) -Promote comfort-anti-anxiety meds -Skin preparation

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Preoperative-Implementation:

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-Leg and deep breathing exercises -ROM exercises -Moving patient -Coughing and splinting

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Pre-operative Teaching:

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-Patient and diagnostic tests -TED socks, elastic wraps, pneumatic compression devices, and early ambulation.

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Preoperative Monitoring:

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1. Sit upright on the edge of the bed or in a chair, being sure that your feet are placed firmly on the floor or stool. (After surgery, deep breathing is done with the patient in Fowler's position or in semi-Fowler's position). 2. Take a gentle breath through mouth then breath out gently and completely. 3. Take a deep breath through nose and mouth, and hold this breath to the count of 5; exhale though nose and mouth

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Deep (Diaphragmatic) Breathing:

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1. Find a comfortable upright position, with knees slightly bent 2. Place hands on each side of lower rib cage, just above waist 3. Take a deep breath though nose, using shoulder muscles to expand lower rib cage outward during inhalation. 4. Exhale, concentrating first on moving chest, then on moving lower ribs inward, while gently squeezing the rib cage and forcing air out of the base of lungs.

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Expansion Breathing:

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1. Unless coughing is contraindicated, place a pillow, towel, or folded blanket over surgical incision and hold the item firmly in place. 2. Take 3 slow, deep breaths to stimulate your cough reflex. 3. Inhale through nose, and then exhale through mouth. 4. On 3rd deep breath, cough to clear secretions from lungs while firmly holding the pillow, towel, or folded blanket against incision.

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Splinting of the Surgical Incision:

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-To promote venous return and prevent DVT. *-Examples:* Kendall SCD machine, sleeves and TED stockings; Venodyne pneumatic compression system; Flowtron DVT calf garments.

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Purpose of External Pneumatic Compression Devices:

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Decrease anxiety by providing a climate of privacy, comfort, and confidentiality. *Interventions Include:* -Preoperative teaching -Encouraging communication -Promoting rest -Using distraction -Teaching family members

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How to relieve anxiety pre and intra-operatively:

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-Complete pre-op checklist sheet in medical record, VS, skin prep removal of prosthetics, hair pins, dentures, bowel and bladder prep, TEDS, IV, NG Tube, ID band, and pre-op medications. Make sure lab informed & radiology reports on chart. Be sure abn. labs reported to MD. *-ALLERGIES*

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What to do on the Day of Surgery:

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IV pole, open bed, suction, Oxygen, emergency kits, and clamps.

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Preparation of Patient's room for return after OR:

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-Patient wears an identification band. -Dentures, prosthetic devices, hearing aids, contact lenses, fingernail polish, and artificial nails must be removed.

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Preoperative Patient Prep:

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*Certain Antibiotics:* combined with curariform muscle relaxant cause respiratory paralysis and apnea. *Anti-Depressants:* MAO inhibitors-second line choice for tx of depression. Cause hypotension effects of anesthesia, St. Johns Wart. Parnate, Nardil. *Phenothiazines:* (Thorazine-antipsychotic. Also for severe NV, seizures) increase hypotension action of anesthesia.

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Medications Hazardous to Surgery:

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*Diuretics:* electrolytes imbalance and resp depression. *Steroids:* inhibits wound healing *Anticoagulants:* warfarin and heparin- affect bleeding, unexpected bleeding; herbals-ASA, ginko, NSAIDS, Ticlid, Plavix.

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Medications Hazardous to Surgery Con't:

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Primary concerns of the nurse is the safety & advocacy for the patient during surgery as the patient is unable to protect or advocate for himself. It is the responsibility of all of the surgical team members to protect the patient.

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Intra Operative Care:

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-Enter prior to OR; nurse continues to prepare patient (insert Foley or start IV). -Nurse assist in transfer to and from OR, maintain proper body alignment.

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Intraoperative Care, Holding area:

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When the procedure involves a specific site, validating the side on which a procedure is to be performed (e.g., for amputation, cataract removal, hernia repair) is the responsibility of each health care professional before and at the time of surgery. Facilities usually have the patient and/or nurse initial the correct surgical site.

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In the OR, ID site of Procedure:

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-Code status -Any allergies -The position pt is supposed to be in -Medical hx -What meds have been taken -Last PO intake.

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NTK Before the Surgery:

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-Supine -Trendelenburg: supine with feet slightly lowered. -Jacknife: like leaning over a table with arms out to the side -Lithotomy: supine with feet in stirrups. -Lateral -Prone

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6 Positions for Surgery:

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A minimally invasive procedure where gas or air is injected into a body cavity before surgery to separate organs and improve visualization.

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Insufflation:

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*General (inhalation, IV, balanced):* depresses the CNS, resulting in analgesia amnesia, and unconsciousness, with loss of muscle tone and reflexes. Used for surgery of head, neck, upper torso, and abdomen. *Regional or local:* *Cryothermia:* *Hypnosis/Hypoanesthesia:*

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What are the 4 types of Anesthesia?

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*Advantages:* Most controllable method; induction and reversal accomplished with pulmonary ventilation; few SE. *Disadvantages:* must be used in combination with other agents for painful or prolonged procedures; limited muscle relaxant effects; *postop nausea and shiver common*; explosive. *Common Agents: Suprance, Ethrane, Fluothane!, Nitrous oxide (N2O)!*

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General Anesthesia, Inhalation:

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*Advantages:* Rapid and pleasant induction; low incidence of postop N/V; requires little equipment. *Disadvantages:* Must be metabolized and excreted from the body for complete reversal; contraindicated in presence of hepatic or renal disease; increased cardiac and respiratory depression; retained by fat cells. *Common Agents: Pentothal!, Ketalar, Diprivan; Hypnotics like versed, ativan, valium are adjuncts to general.*

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General Anesthesia, IV:

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*Advantages:* Minimal disturbance to physiologic function; minimal SE; can be used with older and high-risk patients *Disadvantages:* Drug interactions can occur; pharmacologic effects on the body may be unpredictable. *Common Agents: COMBINATION OF: Nitrous oxide, for amnesia; morphine for analgesia; pavulon (Pancuronium), for muscle relaxation.

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General Anesthesia, Balanced:

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-Opioid analgesic: alfenta, demerol, morphine. -Anticholinergic: atropine, scopolamine -Benzodiazepine: valium, versed -Sedative-hypnotics: atarax, vistaril, seconal, nembutal.

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Name the 4 Adjunctive Anesthetic Agents:

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*-Anesthesia induction* -Alfenta -Demerol and Morphine: pain prevention and pain relief.

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Use of Opioid Analgesic for an Adjunct Agent:

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*-To dry up excessive secretions* -Atropine, scopolamine

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Use of Anticholinergic for an Adjunct Agent:

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*-Amnesia and anxiety* -Valium and Versed

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Use of Benzodiazepine for an Adjunct Agent:

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*-Amnesia and sedation* -Atarax, Vistaril, Seconal, Nembutal

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Use of Sedative-Hypnotics for an Adjunct Agent:

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*Advantages: gag and cough reflexes stay intact (decreases risk for aspiration); allows participation and cooperation by the pt;* less disruption of physical & emotional body functions; decreased chance of sensitivity to agent; decreased intraoperative stress.

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Advantages of Regional or Local Anesthesia:

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*Disadvantages: not practical for extensive procedures b/c of the amount that would be required to maintain anesthesia;* difficult to administer to an uncooperative or upset pt; no way to control agent after administration; absorbs rapidly into the blood and causes cardiac depression (hypotension) or overdose; increased nervous system stimulation (overdose).

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Disadvantages of Regional or Local Anesthesia:

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-Xylocaine -Lidocaine -Novocain *Topical:* Dermoplast (benzocaine)

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3 Common Agents for Regional or Local Anesthesia:

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*Epidural:* Injection into the epidural space (dura mater). For anorectal, vaginal, perineal, hip, & lower extremity surgeries. *Field:* A series of injections around the operative field. For chest procedures, hernia repair, dental surgery, & some plastic surgeries. *Spinal:* Injection into the cerebrospinal fluid in the subarachnoid space. For lower abdominal, pelvic, hip, and knee surgery. *Nerve:* Injection into or around one nerve or group of nerves in the involved area. For limp surgery or to relieve chronic pain.

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4 Types of Regional (which is a form of Local):

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*Advantages: Reflexes remain intact,* decreases chance of adverse reactions, decreased intraoperative stress. *Disadvantages: Not used in long or extensive procedure,* no way to control depth of anesthesia, may not be appropriate for anxious patient.

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Cryothermia Anesthesia:

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*Advantages: reflexes remain intact. Disadvantages:* requires patient cooperation, requires special training. *Induces a passive, trance-like state.*

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Hypnosis/Hypoanesthesia:

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Conscious sedation is the IV delivery of sedative, hypnotic, and opioid drugs to reduce the level of consciousness but allow the patient to maintain a patent airway and to respond to verbal commands.

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Conscious Sedation:

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Versed, Ativan *Flumzazenil/Romazicon:* reversal agent for benzodiazepines (Versed, Ativan)

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What are the 2 common agents used in conscious sedation?

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-Patent airway (ABCs) -Breathing/Oxygenation -Circulation -Therapeutic response to anesthesia -Risk for Injury: proper positioning -Maintain surgical asepsis -Risk for infection. -Surgical site: closure of surgical wounds with stitches, staples, or tapes. Risk for infection.

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Name 7 Intraoperative Nursing Concerns:

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-Hypoventilation -Oral Trauma- endotracheal intubation -Hypotension -Cardiac dysrhythmias -Hypothermia -Peripheral nerve damage -Malignant hyperthermia

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Name 7 Intraoperative Complications:

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Due to abnormal and excessive intracellular collection of Ca+ resulting in hypermetabolism and increased muscle contraction.

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Malignant Hyperthermia:

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-Tachycardia, dysrhythmias, muscle rigidity (especially of the jaw and upper chest), hypotension, tachypnea, skin mottling, cyanosis, and *myoglobinuria* (presence of muscle proteins in the urine). -The most sensitive indication is an unexpected rise in the end-tidal carbon dioxide level with a decrease in oxygen saturation.

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Manifestations of Malignant Hyperthermia:

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-High fever ^ to 111.2F (late sign), tachycardia (early sign) -Dysrhythmias -Muscle rigidity (esp. jaw & upper chest), heart failure -Pseudotetany -Myoglobinuria (muscle protein in urine) -^ CA+ & K+ -Skin mottling/cyanosis

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Name 7 S/S of MH:

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-Discontinue inhalent anesthetic -Give *Dantrium (Dantrolene)* (for risk or previous HX: may give before, during, and after surgery to prevent) -Intubate & oxygen 100% -Cooling: cooling blanket, iced IV saline or iced saline lavage of stomach, bladder, rectum. -More pg 275 Chart 17-1

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Name 4 ways to Treat MH:

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-Overdose of anesthesia -Unrecognized hypoventilation -Intubation complications

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Name 3 Complications During Intraoperative Care:

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-Anesthesiologist and circulating nurse -Must provide a "Hand-Off Report" which allows for 2-way verbal communications, information must be clear & standardized (SBAR), and provides for clarification of information about patient.

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Who is responsible for accompanying pt and providing report to PACU nurses? And what must they provide?

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-Provides ongoing evaluation & stabilization of patients. -To anticipate, prevent, treat any complications of surgery.

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Purpose of the PACU:

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Q15min

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How often should you look at the surgical incision in PACU?

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*Airway:* breathing appropriately? Labored? Why? *Mental Status:* what is it? Is it appropriate? *Surgical incision:* bleeding? Look at it q15min. *VS:* Temp/Pulse/BP *IV Fluids:* solution type, amount in bag, rate *Other Tubes/Drains:* Foley, NG, trach, chest

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What 6 things are monitored in the PACU?

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Immediately assess for patent airway and adequate gas exchange. Although some patients may be awake and able to speak, talking is not a good indicator of adequate gas exchange.

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What do you immediately assess when pt comes into PACU?

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1. Muscular irritability 2. Restlessness and delirium 3. Recognition of pain 4. Ability to reason and control behavior

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What is the order of return to consciousness after general anesthesia?

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1. Sense of touch 2. Sense of pain 3. Sense of warmth 4. Sense of cold 5. Ability to move

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What is the order of return of motor and sensory functioning after local or regional anesthesia?

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Motor and sensory assessment

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What type of assessments are very important after epidural or spinal anesthesia?

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-Begin after the patient's sensation has returned to at least the spinal dermatome level of T10. -You test by gradually elevating the patient's head and monitoring for hypotension.

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When do you test for the return of sympathetic nervous system tone?

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-The passage of flatus or stool. -The presence of active bowel sounds usually indicates return of peristalsis; however, the absence of bowel sounds does not confirm a lack of peristalsis.

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What is the best indicator of intestinal activity?

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-Infection -Distention from edema or paralytic ileus -Stress at the surgical site -Health problems (e.g., diabetes)

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Name 4 causes of ineffective wound healing:

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-Older or debilitated -Diabetic -Crohn's disease -Heart failure

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What 4 patients are more at risk for fluid and electrolyte imbalance?

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-A partial or complete separation of the outer wound layers, sometimes described as "splitting open of the wound" -Occurs most often between the 5th and 10th days after surgery

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Wound Dehiscence:

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-The total separation of all wound layers and protrusion of internal organs through the open wound. -Occurs most often between the 5th and 10th days after surgery

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Wound Evisceration:

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-Obese -Diabetic -Immune deficiency -Malnutrition -Ones using steroids

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What 5 patients does wound separation occur most in?

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-Positioning during surgery, prolonged contact with damp surgical linens, and contact with unpadded surfaces. -Examine the patient's skin for areas of redness or open areas.

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Patients are also at risk for developing pressure ulcers from:

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*Gravity Drains:* Penrose and T-tube; drain directly through a tube from the surgical area. *Closed-Suction Drainage System:* Jackson-Pratt and Hemovac; drain into a collecting vessel.

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What are 4 types of Drains?

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Monitor the dressing for drainage.

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What is monitored with the Penrose Drain?

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Assess suction: compress to re-charge.

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What is assessed for the Jackson Pratt & Hemovac drain?

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-Surgeon changes 1st dressing -Changed to MD order specifications or protocol -Use aseptic technique until sutures/staples removed -Usually changed Qshift w/ sterile saline. May be left open to air -Staples usually removed after 6-8days & steri-strips used; removed by MD or nurse -Note site appearance, temp, drainage -Montgomery Straps -Wound Infections: TX & depridement

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8 Guidelines for Post-Surgical Dressings:

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Are recommended to secure dressings on wounds that require frequent dressing changes. These straps allow the nurse to perform wound care without the need to remove adhesive strips thus decreasing risk of skin irritation and injury. They are prepares strips of nonallergenic tape with ties inserted through holes at one end. Onset of straps is placed on either side of a wound and the straps are tied like shoelaces. • Replace the ties and straps whenever they are soiled or every 2-3 days

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Montgomery Straps

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-Hypotension -Dysrhythmia -Venous Thrombosis -Pulmonary Embolism -Hiccoughs -Abdominal distention (paralytic ileus) -Immobility with skin integrity -Urinary retention, UTI -Wound infection, dehiscence, hemorrhage, evisceration

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Name 10 Complications in Postop:

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-Morphine, Dilaudid, Demerol, Percodan, tylox/Percocet -Assess within 5-10min for hypotension, decreased respiratory. -Give on schedule instead of on demand. -*Narcan* reversal agent for opioids; *Flumazenil/Romazicon* reversal agent for benzodiazepines (versed, Ativan)

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What are the 5 common opioid agents used for post-op pain relief?

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Progress from liquids to regular; NPO till bowel sounds!

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General Anesthesia Post-op Nutrition:

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