Pre-Intra-Post-Op Nursing Care

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Reasons for surgery
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Diagnostic: determines origin and cause of disorder Curative: resolves health problem by repairing or removing cause Restorative: improves patient’s functional ability Palliative: relieves sx of disease process, but does not cure Cosmetic: alters/enhances personal appearance
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Urgency and degree of risk
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Urgency: Elective, Urgent, Emergent Degree of Risk: Minor, Major Surgical home? – may help enhance outcomes in pts if there was a surgical home that coordinated care throughout entire surgical process (pre, intra, post)
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Extent of surgery/procedures
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Simple: localized approach Radical: involves surrounding musculature / area Minimally invasive (MIS): laparoscopy or robotic techniques Bedside, VASC (outpt surgery center @ UVA), Main
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Collaborative management: Assessment
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*History & data collection*: Age; Drugs, Substance use; Medical hx (including cardiac and pulmonary); Complementary/alternative practices; Previous surgeries, anesthesia; Blood donations; Discharge planning *OSA (Obstructive Sleep Apnea) Score*: how likely is that the person has sleep apnea > helps inform airway problems patient may have
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System assessment
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*Cardiovascular*: CAD, MI w/i 6 mos of surgery, angina, HTN, dysrhythmias *BLOOD THINNERS*: HOLD 1 WK b/fore surgery > Xarelto – blood thinner can be used *Respiratory*: Chronic respiratory problems; Smoking decr O2 delivery, diminishes ability to wound heal, skin integrity *Renal/Urinary*: Kidney impairment inhibits drugs/anesthetic agent excretion * Endocrine*: DM, importance of insulin control
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System Assessment Cont
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*Neurologic*: Determine baseline – need to know whether any change in consciousness is typical or not > Assess LOC & ability to follow commands *Musculoskeletal* *Nutritional status*: Malnutrition & obesity increase surgical risk *Psychological*: consent, self care? > is patient able to provide their own informed consent? *Psychosocial*
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Lab Assessments
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Blood type & crossmatch CBC or H/H Clotting studies (PT/INR & PTT) Basic Metabolic Panel (BMP): electrolytes, Creat Pregnancy test: may be contraindication in surgery > weigh risks/benefits Also: CXR, EKG
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Information
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*Preoperative teaching* *Informed consent*: is a process > begins w/ surgeon, ask pt several times what they’re having & where; Surgeon obtains signed consent b/fore sedation and/or surgery; Nurse clarifies facts & dispels myths about surgery: not responsible for providing detailed info about procedure! Pt may sign with “X”; In emergency, telephone authorization is acceptable *Ensure correct site is selected & wrong site is avoided* *Licensed independent practitioner marks site, involving pt if possible*
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Skin preparation
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Break in the skin increases risk for infection Pt may be asked to shower using antiseptic solution Hair removal by electric clippers, depilatories > Shaving creates risk for infection!
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Dietary restrictions
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NPO: Pt not to ingest anything PO for 6-8 hrs before surgery Decreases risk for aspiration Give pts written/oral directions to stress adherence Surgery can be canceled if instructions not followed
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Administering regular medications
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Consult w/ physician and anesthesia provider for instructions Drugs for certain conditions often allowed w/ sip of water: will be person dependent > pt may or may not need to take meds for: Cardiac disease, Respiratory disease, Seizures, HTN
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Bowel/GI prep?
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Performed to prevent injury to colon; reduces number of intestinal bacteria Enema or laxative
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Patient preparation
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Remove most clothing; provide gown Leave valuables with family member or lock up Tape rings in place if cannot be removed Ensure patient is wearing ID band Remove: Dentures, Prosthetic devices, Hearing aids, Contact lenses, Fingernail polish, Artificial nails, Pierced jewelry
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Members of surgical team
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Surgeon & surgical assistant, Anesthesia providers Holding area nurse (SAS), Circulating nurse, Scrub nurse, Specialty nurses Surgical technologist *Safety*: Time-out, Surgical count, Surgical checklist
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Minimally invasive & robotic surgery
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Now common practice Preferred technique for many surgery types, including: Cholecystectomy, Joint surgery, Cardiac surgery (some), Splenectomy, Spinal surgery Ex) Minimally invasive laparoscopic surgery
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Laparoscopy
Laparoscopy
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Can cause referred shoulder pain d/t gas filled area
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Surgical scrubbing
Surgical scrubbing
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Broad-spectrum, surgical antimicrobial solution Vigorous rubbing creates friction Used from fingertips to elbow Scrub continues for 3-5 min
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General anesthesia
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*Reversible* loss of consciousness induced by inhibiting neuronal impulses in several areas of CNS Involves single or combination of agents *Depresses CNS*: results in analgesia, amnesia, unconsciousness w/ loss of muscle tone & reflexes Risk for?
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General Anesthesia (GA) Cont.
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Inhalation IV injection *Adjuncts to general anesthetic agents*: Hypnotics, Opioid analgesics, Neuromuscular blocking agents *Balanced anesthesia*: e.g., nitrous oxide for amnesia, morphine for analgesia, pancuronium for muscle relaxation May need to use a hypnotic, a paralytic, and an analgesic
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Complications from GA
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*Malignant hyperthermia* Overdose Unrecognized hypoventilation Problems with specific anesthetic agents Intubation problems Tachycardia, Skin mottling, Cyanosis Myoglobinuria, Rise in CO2, Elevated temperature
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Malignant hyperthermia
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Acute, life-threatening complication May be genetic Begins when skeletal muscle is exposed to a specific agent Causes incr metabolism of drug > incr Ca++ levels in muscle cells > leads to acidosis, high temperature, dysrhythmias
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Treatment of complications
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Establish open airway *SAFETY*: regaining consciousness Give oxygen Notify surgeon *Epinephrine* for unexplained bradycardia
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Local anesthesia
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Briefly disrupts sensory nerve impulse transmission from specific body area/region Delivered topically and by local infiltration Pt remains conscious, able to follow instructions
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Regional anesthesia
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Blocks multiple peripheral nerves in specific body region: Field Nerve Spinal Epidural
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Moderate sedation
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IV delivery of sedative, hypnotic, opioid drugs to reduce level of consciousness Patient maintains patent airway, can respond to verbal commands Amnesia action is short i.e. colonoscopy
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Common surgical positions
Common surgical positions
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Common skin closures
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Postoperative period
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Begins w/ completion of surgery & transfer to PACU, ambulatory care unit, or ICU Handoff/communication > *Most critical of the transfers* N/V: many anesthesia agents can cause N/V: give Zofran or other antiemetic Airway: want to prevent vomiting if possible Abx order: know when they got the last dose & when the next one is due How cold did the pt get? Do we need warming blankets?
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Respiratory assessment
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Patent airway, adequate gas exchange Note artificial airway when applicable Rate, pattern, depth of breathing Breath sounds Accessory muscle use Snoring and stridor Respiratory depression or hypoxemia
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Cardiovascular monitoring
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Vital signs Heart sounds Cardiac monitoring *Peripheral vascular assessment*: Monitor for DVT, Administer prophylaxis (SCDs)
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Post-op monitoring – Neuro
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Cerebral functioning Motor and sensory assessment after epidural or spinal anesthesia Know LOC before & after surgery
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Post-op monitoring – Fluid/electrolyte
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Monitor I/O, Hydration status, IVF Vomit Urine Wound drainage, NG tube drainage Acid-base balance
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Post-op monitoring – GI system
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Postoperative N/V common: 30% of patients experience N/V after general anesthesia Peristalsis may be delayed up to 24 hrs Monitor for bowel sounds *To reduce nausea/vomiting*: Ondansetron (Zofran), Meclizine (Antivert, Dramamine), Benadryl (I know!), Phenergan
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If NG inserted:
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*May have been inserted during surgery to*: Decompress and drain stomach, Promote GI rest Allow lower GI tract to heal, Provide enteral feeding route Monitor gastric bleeding, Prevent intestinal obstruction *Assess any NG tube drainage*
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Skin assessment
Skin assessment
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*Impaired wound healing*: seen most often 5 – 10 days after surgery *Dehiscence*: wound starts to break apart *Evisceration*: bulging out What impacts wound healing? Nutrition, age, glucose, mobility, tobacco use
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Surgical drains
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Assess drainage q 4h, or PRN
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Post-op Pain
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1) Pain/discomfort expected after surgery 2) Look for Physical & emotional signs of pain 3) Consider type, extent, length of surgery when assessing pt’s pain & need for meds *S/Sx of Pain*: Increased HR/BP/RR, Profuse sweating, Restlessness, Confusion (older adults), Wincing, moaning, crying 4) Make sure you give pt a stool softener
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Lab assessment
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Analysis of electrolytes CBC “Left-shift” on differential: elevated WBCs Anemia? Blood loss? > Check H/H ABGs Urine and renal laboratory tests Blood glucose
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Potential for hypoxemia
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Highest incidence occurs on *DAY 2 postop* *Interventions*: Airway maintenance, Monitor SpO2 Semi-Fowler’s position, O2 therapy, breathing exercises, Mobilization ASAP
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Wound Infection (SSI) & delayed healing
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*Interventions*: Nursing assessment of surgical area *Dressings*: first change usually done by surgeon *Drains*: provide exit route for air, blood, bile; help prevent deep infections, abscess formation during healing Irrigation, debridement, surgical re-open

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