-*Preoperative, intraoperative, and perioperative*
-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.
*Condition of Surgical Procedure:* breast biopsy, exploratory laparotomy, arthroscopy.
*Condition of Surgical Procedure:* Cholecystectomy, appendectomy, hysterectomy.
*Condition of Surgical Procedure:* Total knee replacement, finger re-implantation.
*Condition of Surgical Procedure:* Colostomy, nerve root resection, tumor de-bulking, ileostomy.
*Condition of Surgical Procedure:* Liposuction, revision of scars, rhinoplasty, blepharoplasty.
*Condition of Surgical Procedure:* Cataract removal, hernia repair, hemorrhoidectomy, total joint replacement.
*Condition of Surgical Procedure:* Intestinal obstruction, bladder obstruction, kidney or ureteral stones, bone fracture, eye injury, acute cholecystitis.
*Condition of Surgical Procedure:* Gunshot or stab wound, severe bleeding, abdominal aortic aneurysm, compound fracture, appendectomy.
*Condition of Surgical Procedure:* Incision and drainage (I&D), implantation of a venous access device (VAD), muscle biopsy.
*Condition of Surgical Procedure:* Mitral valve replacement, pancreas transplant, lymph node dissection.
*Condition of Surgical Procedure:* Simple/partial mastectomy.
*Condition of Surgical Procedure:* Radical prostatectomy, radical hysterectomy.
*Condition of Surgical Procedure:* Arthroscopy, tubal ligation, hysterectomy, lung lobectomy, coronary artery bypass, cholecystectomy.
-Assess to identify problems that warrant further patient assessment or intervention before the procedure
-Obtains baseline vital signs
-Age; discharge planning
-Drugs and substance use
-Medical history, including cardiac pulmonary histories
-Previous surgical procedures & anesthesia; blood donations.
-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
-If the patient is a minor, a guardian, parent or court order will sign the permit; the state dictates that age.
-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.*
-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).
-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.
-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.
-Enema or laxative may be ordered by the physician.
-Perform skin preparation to decrease the risk of impairment of skin integrity.
-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.
-Shaving is now considered an inappropriate hair removal method; only clippers or depilatories are to be used for hair removal.
-Patients who are dehydrated or are at risk for dehydration may receive fluids before surgery.
-Nutrition/fluids-IV; NPO after MN
-Hygiene- skin scrub; remove nail polish, hair pins, hospital gown.
-Special orders (insert tubes, medications)
-Promote comfort-anti-anxiety meds
-Coughing and splinting
-TED socks, elastic wraps, pneumatic compression devices, and early ambulation.
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
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.
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.
*-Examples:* Kendall SCD machine, sleeves and TED stockings; Venodyne pneumatic compression system; Flowtron DVT calf garments.
-Teaching family members
-Dentures, prosthetic devices, hearing aids, contact lenses, fingernail polish, and artificial nails must be removed.
*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.
*Steroids:* inhibits wound healing
*Anticoagulants:* warfarin and heparin- affect bleeding, unexpected bleeding; herbals-ASA, ginko, NSAIDS, Ticlid, Plavix.
-Nurse assist in transfer to and from OR, maintain proper body alignment.
-The position pt is supposed to be in
-What meds have been taken
-Last PO intake.
-Trendelenburg: supine with feet slightly lowered.
-Jacknife: like leaning over a table with arms out to the side
-Lithotomy: supine with feet in stirrups.
*Regional or local:*
*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)!*
*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.*
*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.
-Anticholinergic: atropine, scopolamine
-Benzodiazepine: valium, versed
-Sedative-hypnotics: atarax, vistaril, seconal, nembutal.
-Demerol and Morphine: pain prevention and pain relief.
-Valium and Versed
-Atarax, Vistaril, Seconal, Nembutal
*Topical:* Dermoplast (benzocaine)
*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.
*Disadvantages: Not used in long or extensive procedure,* no way to control depth of anesthesia, may not be appropriate for anxious patient.
Disadvantages:* requires patient cooperation, requires special training.
*Induces a passive, trance-like state.*
*Flumzazenil/Romazicon:* reversal agent for benzodiazepines (Versed, Ativan)
-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.
-Oral Trauma- endotracheal intubation
-Peripheral nerve damage
-The most sensitive indication is an unexpected rise in the end-tidal carbon dioxide level with a decrease in oxygen saturation.
-Muscle rigidity (esp. jaw & upper chest), heart failure
-Myoglobinuria (muscle protein in urine)
-^ CA+ & K+
-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
-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.
-To anticipate, prevent, treat any complications of surgery.
*Mental Status:* what is it? Is it appropriate?
*Surgical incision:* bleeding? Look at it q15min.
*IV Fluids:* solution type, amount in bag, rate
*Other Tubes/Drains:* Foley, NG, trach, chest
2. Restlessness and delirium
3. Recognition of pain
4. Ability to reason and control behavior
2. Sense of pain
3. Sense of warmth
4. Sense of cold
5. Ability to move
-You test by gradually elevating the patient’s head and monitoring for hypotension.
-The presence of active bowel sounds usually indicates return of peristalsis; however, the absence of bowel sounds does not confirm a lack of peristalsis.
-Distention from edema or paralytic ileus
-Stress at the surgical site
-Health problems (e.g., diabetes)
-Occurs most often between the 5th and 10th days after surgery
-Occurs most often between the 5th and 10th days after surgery
-Ones using steroids
-Examine the patient’s skin for areas of redness or open areas.
*Closed-Suction Drainage System:* Jackson-Pratt and Hemovac; drain into a collecting vessel.
-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
-Wound Infections: TX & depridement
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
-Abdominal distention (paralytic ileus)
-Immobility with skin integrity
-Urinary retention, UTI
-Wound infection, dehiscence, hemorrhage, evisceration
-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)