Preoperative Nursing – Flashcards
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Surgery, definition and purposes
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Surgery Art and science of treating diseases, injuries, and deformities by operation and instrumentation Performed for Diagnosis- biopsy, colonoscopy Cure- appendectomy Palliation- for pain, cut nerves to alleviate pain Prevention- mastectomy b/c family history of breast cancer. Exploration- open abdominal cavity to explore cause of extreme abdominal pain Cosmetic improvement- plastic surgery
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Elective surgery vs. emergency surgery- inpatient vs outpatient
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Elective surgery vs. emergency surgery- elective- knee replacement, gastric bypass. Emergency- trauma Inpatient- more than 24 hour stay Same-day admission-Ambulatory (outpatient): less than 23 hour stay
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Your Role Preop-
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Obtain health history, collect baseline data, education, medications (OTC & herbal remedies), allergies, assess lab results identify risk.
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Patient Interview
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1. Purpose is to obtain baseline data 2. evaluate patient coping building rapport with the patient. 3. provide and clarify information about the planned surgery, including anesthesia assess emotional/readiness
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surgical procedures
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ectomy
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removal of
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lysis
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destruction of
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orrphaphy
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repair or suture
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oscopy
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look into
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otomy
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cut into/incision of
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plasty
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reconstruction
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Nursing Assessment overall goals
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Overall goals Identify risk factors. Plan care to ensure patient safety. - very important in the OR because nurse must advocate for the patient who is witness inform consent, pt's drug list, results of lab work
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Health history
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Diagnosed medical conditions (previous and current) Previous surgeries and problems Menstrual/obstetric history - ensure they are not pregnant Reactions or problems with anesthesia- malignant hyperthermia, genetic condition where patient has hyperthermia due to anesthetic
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Psychosocial assessment
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Excessive stress response can be magnified and affect recovery. Anxiety- affects patient learning and excessive stress response affects their recovery Fears- , may be afraid of death, the unknown, the pain, how long recovery will take, finances Hope-positive attitude
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Cardiovascular
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murmurs, hypertension, heart disease, heart failure, ID any drugs that may affect coagulation, assess edema, inspect neck veins for distention, obtain baseline BP, assess all pulses, 12 leads ECG, coagulation studies.
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Allergies(drug and nondrug)-
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nausea, constipation, diarrhea, or idiosyncratic (opposite than expected reactions). A true drug allergy results in anaphlylatic reaction causion cardio pulmonary compromise (hypotension, tachycardia, and bronchospasm), be aware of nondrug allergies, specifically food, environmental (latex, pollen and animal), SE, Risk factors, history of action
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Respiratory
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COPD, any use of CPAP machine, respiratory infections, smoking, history of respiratory issues, PPD, assess for cough, dyspnea, and accessory muscles of respiration, assess for adventitious sounds. stops smoking 6 weeks prior. greater pack= greater risk/
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Nervous
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orientated x3 (manic/dementia symptoms once they awake from surgery if not orientated. Impairment of vision/hearing (take off glasses so they will not be damaged but leave in hearing aids for communication), do they follow commands and find baseline mental status, history of strokes, ischemic attacks or other neuro disease
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Genitourinary
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- urinary infection, BUN, serum creatinine, electrolytes (dehydration), color characteristics of urine, access for hCG hormone ( pregnancy)
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Hepatic
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liver function should be assessed by looking at AST and ALT because liver breaks down medication and anesthesia. The liver also produces prothrombin for clotting. As well as metabolizes nutrients for wound healing. Check to see if patient is anemic. Assess abuse of alcohol, any signs of jaundice
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Integumentary system & Musculoskeletal system-
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pressure points need to be padded especially if they are very skinny due to bony prominences. ID any previous skin disorders (pressure ulcers, eczema), note skin status, inspect for rashes, boils, infections, assess turgor, mucous membranes, moisture and temperature, joint/muscle pain, ROM, mobility gait and balance
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Endocrine
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diabetes & other hormone replacement medications often need to be adjusted before surgery, always alert the physician and ACP. Uncontrolled diabetes predisposes patient for slow wound healing and infections due to damaged capillaries.
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Immune
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any immune deficiencies and immune suppressants and corticosteroids need to be brought to the physician's attention.
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Fluid & Electrolyte Status
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make sure the patient is well hydrated and ask about any vomiting/diarrhea. You also need to know if they are on any diuretics.
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Nutritional status
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Obesity- lack of capillaries due to heavy weight Stresses cardiac and pulmonary systems Increased risk of wound dehiscence and infection Slower recovery from anesthesia Slower wound healing Provide extra padding to underweight patients to prevent pressure ulcers. Identify dietary habits that may affect recovery (e.g., caffeine- causes withdrawal headaches) Last bowel movement, auscultate for bowel sounds
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Physical Exam (objective)
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All patients admitted to the OR must have a documented H&P in chart Document relevant findings, and report to perioperative team. Obtain and evaluate results of laboratory tests. Obtain a baseline for the patient to identify problems
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Preoperative Teaching & benefits
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Patient has right to know what to expect and how to participate. How will this help a patient?- preoperative teaching lessens anxiety and make the patient well prepared for post op when they may be drowsy, in pain when learning will be less effective.
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Three types of preop teaching
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• Sensory- what the patient will see, smell, and feel in OR • Process- where and when they will go, what equipment will be used, where caregivers may stay while in surgery. • Procedural- example putting in an IV, changes in surgery time, what food is restricted prior to surgery, purpose of frequent VS, pain control, why turning coughing and deep breathing is necessary for the pt postop
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What teaching is needed?-
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when they can eat, meds they need to stop prior to surgery, who will drive them, pain management, how long it will take, food and fluid restrictions, clear liquids what are they and when they need to stop: Need to stop clear liquids 2 hrs prior to surgery and no food 6-8 hours prior to surgery.
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Legal preparation- all forms required to be signed and in chart are:
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• Informed consent • Blood transfusions • Advance directives • Power of attorney
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consent for surgery
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Informed consent must include • Adequate disclosure- given to pt by surgeon(includes risks, consequences, possibility of death, prognosis if not surgery) • Understanding and comprehension • Voluntarily given consent
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What is the role of the surgeon with informed consent?
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Inform the patient of risks, consequences of the surgery, possibility of death, prognosis if there is not surgery, and insure the patient fully understands this.
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What is the role of the nurse with informed consent?
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Witness the patient signing informed consent. Nurse should be patient advocate and ensure no coercion for signature.
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Consent for surgery
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Medical emergency may override need for consent. Legally appointed representative of family may consent if patient is Minor Unconscious Mentally incompetent
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emancipated minor
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if they have their baby, they can make their own decision.
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Day-of-surgery preparation preoperative checklist
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height, weight, allergy, vital signs, signed consent, blood type dx studies, surgical site, ID band, vital signs before surgery, NPO status, void, preoperative meds, valuables.
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Preoperative Medications
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Benzodiazepines, anticholinergics, opiods, antiemetics
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Benzodiazepines
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used for sedative and amnesic properties
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Anticholinergics
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given to reduce secretions
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Opioids
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decrease pain and intraoperative anesthetic requirements
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Antiemetics
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decrease nausea and vomiting
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1. Differentiate the common purposes and settings of surgery- what will the nurse need to do
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1. know nature of disorder requiring surgery amd coexisting medical problems 2. ID patients stress repsonse to surgery 3. Know results of appropriate preoperative diagnostic tests. 4. ID potential risks and complications associated with the surgical procedure and any coexisting medical problems that should be included in the plan of care. 5. communicate & document report of preoperative assessment.
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2. Apply knowledge of the purpose of a preoperative nursing assessment.
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-determine psychologic status -determine
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Current medications
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Prescription and OTC (aspirin is a blood thinner which poses a large bleeding risk they must stop taking aspirin as much as 1-2 weeks before surgery) Antidepressants- can potentially block anesthesia. Antihypertensive- interfere with anesthetic's vasodilation action and predispose pt to shock. Insulin or oral hypoglycemic agents may require dose or agent adjustments during perioperative period due to decreased metabolism, oral intake, the stress, and anesthesia. Antiplatelet and nonsteriodal anti-inflammatory drugs inhibit platelet aggregation and may contribute to postop bleeding. Herbs- Dietary supplements: can cause excessive bleeding which may require return to OR Recreational- • Drugs • Alcohol • Tobacco Recreational drugs interferes with patient recovery and can react with anesthesia. Complications are increased with alcohol because liver function decreased. Could also have alcohol withdrawal during surgery.
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Apply knowledge of the components of a preoperative nursing assessment.
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• Pschologic status (don't use medical jargon, communicate patient concerns to physician.) • Physiologic factors that directly/indirectly affect surgery • Establish baseline • ID and document side and site of surgery • ID drugs- prescription & OTC, herbal • Document lab results & communicate them to physician • Assess teaching needs about procedure • Ensure signed & witnessed consent is in chart
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Common causes of fear in surgery
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death, anesthesia, pain, mutilation of body and body image after surgery, fear of disruption in body function, financial concerns (address these fears, consult with pt care giver, social worker, spiritual advisor)
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• Insulin/oral hypohylcemic agents
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may require dose or agent adjustments during perioperative period because of increased body metabolism decreased oral intake, stress, and anesthesia.
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Interpret the significance of data related to the preoperative patient's health status and operative risk.
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Refer to systems in flash cards • Past health history- family history, past hospitalizations, problems with anesthesia, • Medications
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antidepressants
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potentiate effect of opioids.
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• Antihypertensive
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predispose drug to shock due to combined effect of drug and vasodilator effect of anesthetic agents.
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• Insulin/oral hypohylcemic agents-
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may require dose or agent adjustments during perioperative period because of increased body metabolism decreased oral intake, stress, and anesthesia.
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• NSAIDS
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inhibit platelet aggregation that may contribute to post operative bleeding
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• Patients on anticoagulation therapy (warfarin)-
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Options depending on the patient 1. Continuing therapy 2. Withholding therapy for a time before and after surgery 3. Withholding the therapy and starting subcutaneous or IV heparin therapy during the perioperative period.
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• Herbal
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can cause excessive bleeding
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• Recreational drugs and alcohol
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affects the type of anesthesia used. Alcohol decreases metabolism of anesthesia and they can go into alcohol withdrawal.
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Preoperative teaching-
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must include information focused on patient recovery & safety . Provide written materials and reinforcement, provide balance on information given- too much could overwhelmed and not too little that they are un-prepaired. Increased anxiety impairs learning. Teach sensory information- what they will feel, see hear, smell in OR. Process information- patient transfers, visits, procedural information- IV will be started in holding area.
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Fasting periods MINIMUM-
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clear liquids (water clear tea coffe carbonated beverages, fruit juice without pulp- 2 hr, breast milk- 4, nonhuman milk and infant formula- 6 hr, light meal (toast and clear liquids)- 6, regular meal (fried or fatty food meal)- 8 or more.
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Analyze the components of informed consent for surgery.
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• Informed consent- active, shared decision making process between the health care provider and recipient of care. 1. Adequate disclosure of diagnosis- purpose of proposed treatment, risks and consequences of the proposed treatment, probability of a successful outcome, the availability, benefits, and risks of alternative treatments, prognosis if no treatment 2. Clear understanding before sedation 3. Give consent voluntarily- no coercion • Nurse may witness consent
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Prioritize the nursing responsibilities related to day-of-surgery preparation for the surgical patient.
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• Final preoperative teaching • Assessment • Communication of pertinent findings • Ensure all preoperative orders are done and that the chart is complete and accompanies the patient to the OR. • Ensure signed informed consent in chart, laboratory and diagnostic data, baseline vitals, completed nursing notes, site and side of anticipated surgery and indicate patient agrees. • No nailpolish, artificial nails, makeup, allergy ID band, all valuables with family, no jewelry or piercings, make sure they go to bathroom first
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REFER TO TABLES TABLE 18-6 TABLE 18-7 TABLE 18-8
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