Perioperative Care

Definition Of Perioperative Nursing:
The surgical experience from the time the patient goes to see a physician and makes the decision to have surgery until they are released from their surgeon, usually about six weeks after the surgery.
Perioperative Nursing is divided into 3 phases:
-Preoperative phase
-Intraoperative phase
-Post-operative phase
Define Preoperative phase.
begins with the patient making the decision to have surgery (visiting the doctor for the first time) until the patient is transferred into the operating room of the surgical center. ***Can last weeks, months, or minutes
Define intraoperative phase.
only in the OR
Define post-operative phase.
begins when the patient is admitted to the PACU until they have their follow-up evaluation at the doctor’s or at home
Describe the Preoperative Evaluation/Assessment.
-Must be done by an RN
-Initiates the Preoperative Assessment
-Initiates teaching appropriate to the patient’s need and type of surgery
-Involves family in the interview
-Ensures completion of preoperative diagnostic testing
Verifies understanding of the surgeons preoperative orders
-Begins discharge planning by assessing post-operative needs for transportation and home care.
-Discusses, reviews advanced directives if present
Describe the Circulating Nurse and their responsibilities.
-Must be an RN
-This role is performed during the surgery in the OR
-Ensuring the nursing process is carried out in the operating room.
-Running the room and the surgical team
-Taking labs, biopsied specimens to the lab, etc.
-Monitoring and assessing the patient’s VS, UOP, body temperature, body positioning during the surgery etc.
Describe the Scrub Nurse and their responsibilities.
-Does not have to be a nurse; Can be a Surgical Tech
-This role is performed during the surgery in the OR
-Set up the room and equipment
-Assist the surgeon and surgical team
-Count the sponges, needles, & instruments with the circulating nurse…count before surgery and twice after surgery
Describe the Post Anesthesia Care Unit (PACU) nurse and their responsibilities.
-Must be an RN
-This role occurs in the PACU or the recovery room
-Responsible for Physiologic functioning
-Responsible for Safety of the patient during recovery from the general anesthesia or other medications
Postoperative Assessment:
-Initial Assessments Must Always be performed by a nurse
-Postoperative assessment is completed 2 parts:
1st part is done before the patient leaves the PACU and
2nd part is done initially when the patient arrives to the medical floor, intensive care unit, or before being discharged to home.
Describe the Nurse Educator/Discharge Nurse and their responsibilities.
-Must be an RN
-Is responsible for teaching the patient the information needed to go home and recover without complications secondary to the surgery
Exploratory/Diagnostic =
to confirm a diagnosis or make a diagnosis or to investigate a problem (biopsy)
Palliative =
to alleviate pain; prolong life or relieve symptoms (remove a tumor or put in a feeding tube)
Reconstructive/Reparative =
to improve function or mobility or to repair tissues
Therapeutic =
To provide vascular access
Constructive=
to correct a malformation
Curative=
to restore normal physiological functioning
Surgical Risks:
-Young little reserves
-Elderly decreased reserves
-Obesity greater risks for complications/ infection
-Immuno-Compromised
-Chronic Disease / Debilitated
-Emergency or Emergent =
-Urgent =
-Required =
-Elective =
-Optional =
-Without delay to save a life
-Within 24 to 48 hours to prevent damage
-Need to have within a few weeks
-No ill effects if not have surgery
-Not have to have; the patient decides
Major surgery =
opens the chest, cranium, or abdomen and has a high degree of risk
Minor surgery=
Performed with little risk and few complications as knee surgery
-Same day admit stay=
-Inpatient admit stay=
-Ambulatory =
– < 24 hours - > 24 hours
– d/c home after surgery
Physiological Effects Of Surgery
Neuro-Endocrine:
-Body only has one way to respond to stress =Responds by releasing those hormones involved in the stress flight or fight response
-Stress Response mainly is to:
Maintain fluid & electrolytes; provide nutrients to the body cells, control bleeding, & repair damaged tissues.
Physiological Effects Of Surgery
Cardiac And Respiratory:
-Surgery is a stress to your body and causes release of catecholamines , ADH, and RAA
-BP, HR, and RR all increase.
-Sodium and fluid are retained = Increased total fluid volume
-Vasoconstriction in the peripheral vascular vessels
-Increased blood coaggulability increases clotting & clots
Physiological Effects Of Surgery
Nutrition:
-Stress increases blood glucose level via secretion of cortisol
-Elevated blood glucose level maintains increased metabolic rate
-Must maintain a diet high in vitamins A and C to help restore tissues and promote wound healing
-Decreased insulin production
-Increased glucagon secretion from the liver
-Bowel Sounds decrease
-Gastric mobility decreases ; Paralytic Ileus may result
-Gastric emptying increases = N/V
Physiological Effects Of Surgery
Increased Risk Of Infection:
-Metabolic disorders as Diabetes must be well controlled with blood glucose level <200 or will increase risk of infection (Bacteria love glucose) -Prophylactive antibiotics , usually a cephalosporin as Ancef; Can be given immediately before surgery or during surgery so circulating level of antibiotic is high before incision; then -Antibiotics given prophylactically after surgery for 24 to 48 hours -Obesity greatly increases the risk of infection (Adipose tissue) -Alcoholics have increased risk of infection due to malnutrition and debilitated state from the alcohol
Physiological Effects Of Surgery
Elimination:
-Prior to surgery NPO, decreased PO intake ; so can be decreased after surgery
-Stress causes vasoconstriction and stimulation of R-A-A system so the urine output decreases
-Bowel function decreases due to preps and NPO status
Physiological Effects Of Surgery
Sleep and Rest is Disrupted:
-Anxiety
-Preoperative activities
-Medications
-Physical Pain
-Changes in normal diet
-Changes in normal routines
-Separation from family, pets,
-Uncertain outcomes
Factors Affecting The Surgical Outcome:
-Present Health Status or Co-Existing Health Problems
-Present Medication Therapy
-Nutritional Status/Hydration Status
-Tobacco, Drug Or Alcohol Use
-Life-Style Patterns
-Religious/Cultural Factors
-Development Factors/Age
-Psychosocial Status
-Knowledge Base/Assess
Effects of Medications on Surgery
Corticosteroids=
can cause circulatory collapse & decreases the immune system
Diuretics=
causes electrolyte imbalances during surgery & can result in respiratory collapse
Anticoagulants/NSAID/Aspirin=
Increase the risk of bleeding
Phenothiazines/MAOI=
Increase the hypotensive effects of anesthetics
Antibiotics=
Mycin (Clindamycin) cause muscle paralysis & Apnea if take with muscle relaxant in the OR
Anticholinergics=
Increase confusion in the patient
Anti-Depressents=
Increase hypotensive effects of medications; must stop before surgery (Coumadin, Aspirin, NSAID)
These decrease platelets, blood viscosity, & wound healing:
certain herbs & OTC meds (Fish oil, Garlic, Vit. E, St. John’s Wort
Vit K=
Vit A & C=
Iron=
Protein=
-used for clotting
-used for wound healing
-replaces losses from loss of blood
-used for tissue repair & plasma proteins
Pt. needs to stop smoking at least ___ weeks before surgery.
4 – 8
Preoperative Protocols
Skin:
-Not shaved any longer because of chance of infection before surgery.
-If need to remove hair is done with clippers right before surgery; OR is a sterile environment
-Remind patient not to shave the day of surgery
-Keep the patient’s temperature WNL
-Remove all lotions, powders, jewelry, etc.
-Assess for prior skin integrity issues.
-Often told to bathe in certain soap (Hibiclens, etc) the night before surgery and that morning to decrease normal flora bacteria
Preoperative Protocols
Gastrointestinal:
-Keep NPO = nothing at all by mouth to prevent aspiration
-If patient has had something to eat & or drink then must notify the surgeon and the anesthesiologist of what and how much before the surgery
-Could have an NGT to LIS or just for gravity flow
-Must maintain IV access for fluids to maintain hydration & for medications
Preoperative Protocols
Elimination:
-Must know when the patient had their last stool &/or if they are constipated before surgery.
-Must be sure patient has an empty bladder when going into the OR
-DO NOT EVER ambulate a patient to the bathroom after they have had their pre-operative medication.
~The patient has to use a urinal or bedpan.
-The last action done before transporting the patient to the OR is to have the patient empty their bladder.
~ This task prevents bladder trauma
-Must give any preoperative bowel prep as Golytely, enemas, laxatives, suppositories, etc. as these tasks:
~ Evacuate the bowel and decrease spillage of any abdominal contents during surgery that can cause peritonitis or infections
~ Prevents contamination with stool
~ Allows MD to see better
Preoperative Protocols
Safety:
-Patient is transported on a stretcher or in a wheelchair to the OR
-Patient must be strapped to the stretcher & covered with a sheet
-Identification bracelet must be on the patient
What should be on a patient’s chart before they get to the OR?
-List of all Allergies
-Consent form
-Verify maintained NPO status
-Medication record
-Verify medications given if ordered, held if ordered (Clarify whether to give or not if in doubt!!!)
-Pre-operative check list
-Nursing Note/Documentation
-Current Lab/Procedure Results
Post-op Ambulation:
-Must ambulate to a chair on the day of surgery called post op day zero (0)
-The MD writes the ambulation orders; if none written then patient is ambulated to a chair in the room on the day of surgery once awake and the anesthesia wears off
-On post op day one or the first day after surgery and all other days: Must then ambulate 3 to 4 times a day out in the hall or around the room if on isolation
-Prevents venous stasis, DVT’s, & Bone complications
-Must Dorsiflex the ankles every 2 – 4 hours when in bed if awake and not have on SCD’
Post-op pain can lead to:
-increased healing time
-Respiratory complications r/t hypoventilation
How can a full bladder cause pain?
increases the pressure on damaged, tender tissue from surgery and increases pain
Know the definition of these 7 types
General = only one excreted via the lungs, Intravenous, Moderate, Regional, Local, Epidural, Spinal
Anesthesiologist is responsible for monitoring the patient’s:
-VS
-color
-temp
-LOC
-pupils
-gag reflex
Transfer from the OR to the PACU:
-A full report is given to the PACU (recovering) RN about the surgery and happenings
-Any MD orders are communicated to the PACU RN
-The anesthesiologist will assess the patient throughout their PACU stay
A patient remains in the PACU until:
-fully recovered from the anesthetic agent= Must have stable BP, respiratory function, oxygen saturation equal to their baseline, & stable LOC.
What does Aldrete assess?
-LOC, Respiration, BP, Activity, & O2 Sat
-Patient must have a score of 8 to 10 to leave PACU
Discharge from the PACU is by the ___ approval or order.
anesthesiologist’s
A Full Report is given from the PACU RN to the Intensive Care or Medical Floor receiving RN to include:
-Type of Surgery
-Family Present
-IVF given total amount; IVF running
-UOP during surgery & PACU
-Last time voided; foley inserted
-Drains inserted
-Estimated blood loss
-Any meds given in OR & PACU
-Any Problems in the OR or PACU
Post-op Respiratory Interventions:
-Oxygen as needed
-VS every 4 hours
-Suctioning every 4 hours
-IS & TCDB every 2 hours
-Position with HOB elevated 30 to 45 degrees
-Position side lying
-Give respiratory treatments as ordered
-Maintain Hydration Status
Do not worry about fever until 48 hours post -op unless ___.
> 101
Assess for stool by ___ day post op.
3rd to 4th
Paralytic Ileus is present usually if no bowel sounds in 72 hours
Paralytic Ileus
What meeds are given for N/V?
-Zofran
-Phenergan
Pt. should regain ability to void in ___ hours.
6-8
First 24 hours can be low UOP due to:
-NPO
-fluid restrictions before surgery
-loss of blood
-increased ADH
-drainage
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