205 Perioperative care class notes

Perioperative Nursing
N205 Fall 2007

Learning Objectives:
Explains the various types of surgery according to degree of urgency, degree of risk, and purpose.
Describes the phases of the perioperative period.
Demonstrates essential aspects of preoperative teaching, including pain control, moving, leg exercises and coughing.
Identify essential aspects of preoperative assessment.
Identify nursing responsibilities in planning perioperative care.
Describes essential aspects of preparing a patient for surgery, including skin preparation.
Compares various types of anesthesia.
Identify nursing assessments and interventions during the immediate postanesthetic phase.
Summarize five postoperative complications, their prevention, and their management.
Describe anxiety in terms of etiologies and nursing process and applies content to the management of the anxious patient.

ANXIETY

State of mental apprehension or dread, often initiated by feeling a loss of control.
Can be experienced at many levels (conscious or subconscious). Most anxiety is subconscious—most people don’t have awareness of anxiety
Four levels of anxiety: mild, moderate, severe, and panic.
Behavioral signs: rapid speech, pacing, increased heart and resp rate. Fidgeting repetitive motion, hair, nails, asking same question repeatedly, inappropriate speech
Physiologic signs and symptoms: flight or fight response (sympathetic nervous system response) - heart rate, B/P and respiratory rate increase. Blood vessels constrict as blood is shunted away from skin, stomach and kidneys. Catecholamines increase BP—which is bad pre-surg b/c we want the strain on the heart to be lowered. Post op anxiety increases bleeding, sometimes people will pull out tubes, become combative, try to get up out of a gurney before they’ve come out of anesthesia. Some people hover pre-operatively over every little detail.
Emotional and defensive responses – withdrawal, anger, denial, agitation.
Anxiety and activity response – increased movement, impatience, decreased concentration, repetitive speech, constant talking, overstimulation, hypervigilance.
Environmental interventions: Decreasing anxiety pre-op: have to work w/ the environment you’re in: ask the pt to bring headphones for themselves for nice music, decrease noise level, stimulation.
Behavioral interventions. Post op-people’s brainstems are active, their frontal lobe doesn’t wake up for a while. Preop behavioral interventions: breathing deeply and slowly. Give people control: don’t tell them they have to take their panties off—the power struggle will escalate. Work with them—they’ll be knocked out soon enough anyway.
Pharmacologic interventions: ativan—more than valium which is longer acting; versed [resp depression risk…not used too often]
Set limits, give limited choices, be calm but assertive.
Anxiety as it relates to the perioperative experience.

Want to maintain normothermia post op, warmth calms patients, the veins constrict and makes it hard to start an IV, normothermia prevents all sorts of complications including infections.

PERIOPERATIVE NURSING
Concepts of surgery:
Multidisciplinary approach
Effective communication (timeout): Communication is regulated and standardized for surg b/c the risk of wrong pt, wrong surg etc. The comm. Format is called “time out:” in this case the whole team stops to review the patient, the surgery, etc.
High quality care: hospital ratings are based on care, esp in surg b/c the results are so measureable.
Patient and family advocacy: Role of the RN: pt and family advocacy, like when the pt doesn’t understand their surg, want to talk to the MD, won’t sign the form, etc. Pts have a right to know.
Cost containment: same day vs. inpatient: there’s a lot of trends toward outpatient surg, esp like laproscopic. Pts out of the hosp are better off b/c lower risk of infection.
Pre, intra, and postoperative periods.



Types of surgery:
Degree of urgency: emergency and elective. Emergent: appendectomy, pts who come to the ED first—very little planning or prep. A cardiac bypass w/ an MI would be an emergent surgery. Trauma post MVA. Trauma 1 vs Trauma 2 centers. Elective: plastic, joint replacements, mastectomy, colectomy, etc.
Degree of risk: major and minor: tonsillectomy, repair of torn meniscus, open reduction of a fracture…would all be lightweight. Major surg is open-heart, anything abdominal b/c of the risk rate of bleeding and heat loss, long recovery time.
Purposes: diagnostic, palliative [debulking a tumor to prolong life, decrease pain], ablative, reconstructive, constructive, transplant, and cosmetic (examples of each).
By surgical service – neuro, cardiac, orthopedic, general, vascular, gynecologic, plastic, etc. what type of doc is operating. Some hospitals have services organized by floor.

Phases of the perioperative period –preop (briefly describe) intraop (briefly describe) post-op- PACU to discharge.

Preoperative:
Assessment: ASA classification: for anesthesia, its about the degree of risk based on comorbidity. Goes from 1-6. This rate is about which patients can go to outpatient surgery sites. Anesthesiologists read H/P and decide the rating.
ASA I; normal healthy patient
ASA II mild systemic disease
ASA III severe systemic disease
ASA IV severe disease with threat to life
ASA V moribund patient
ASA VI brain dead patient, organ donation
Planned surgery: doctor, procedure explained, scheduled, preoperative tests ordered, preoperative nursing interview: likely when pts have been dealing w/ illness or injury for some time, planned w/ doc, pt chooses timing, it’s not emergent, etc.
Unplanned: phases abbreviated patients less prepared, preoperative testing done immediately, less teaching done. Knowledge deficit, anxiety
Health problems that increase surgical risk.

Preop nursing assessment:
Current health status, allergies, medications, NPO status, last void, baseline vital signs, smoking, language barriers, social/family resources (ride home, home care): go over this w/ client b/c some people think they don’t have any problems but they’re on 20 heart meds. Sometimes people are in for CABG and they think they’re healthy.
Driving: safe discharge: people often don’t know that they can’t drive themselves home—that’s our responsibility if they get in an accident driving themselves home.
Cultural and spiritual considerations: some people want to have a family reunion at the hospital when they have surgery. Sometimes the patriarch answers the questions for the patient and family.
Prophylactic antibiotic dose.
Check doctor’s orders.
Surgical consent must be signed: this is the nurse’s job—getting the signature. This is highly regulated—no abbreviations, perfect spelling, etc.

Preop teaching – educate about the phases (will be asked for name and date of birth many times), pain control, nausea, prevention of infection (antibiotics), DVT prevention, postop ambulation, coughing and deep breathing. Goal: patient knows what to expect. Make sure patient has a ride home. This is about anxiety, knowledge deficit. Tell people the basics before surg, don’t give them lots of info and details preop. Details happen way before cut day. Tell them about the funny stockings, the tubes, when their family can show up, etc. All surg pts get an IV.

Preparing patients for surgery:
Nutrition and fluids – don’t make patient NPO without starting IVF.Hygiene – preop shower
2. Medications these days patients can often take their own meds preop—this is up to the anesthesiologist; usually heart meds are ok b/c they reduce strain on the heart. No blood thinners allowed. most pts get antibiotics preop b/c we’re opening them up. Has to be given 1 hr b4 cut time. Sometimes anesthesiologist is the one to give it.
3. Special orders:
allergies: we have to ask about their allergies; often people don’t know the difference btwn ‘sensitivities’ and allegies that can cause anaphalactic shock—morph makes most people itch—it’s a side effect not an allergy.
Last time people voided: need to know b/c sometimes people can’t urinate and they get super high BP
Most people come in dehydrated: so I/O is super important.
Know peoples baseline: b/c we don’t want to give dopamine to someone whose BP is very low.
Smoking Hx: will they go thru withdrawals during their stay, O2 requirements, etc.
4. Skin prep; hair removal [electric clippers are used these days—so less infection and dermabrasion—studies show that shaving is way more dangerous than leaving all the hair there.] Chloraprep [chlorhexadine gluconate]
Also keep glucose levels up: the anxiety levels will cause the SNS response of extra glucose in the blood.
5. Safety protocols
6. Deep vein thrombosis prophylaxis:
Questions Preop: what have you eaten, what’s your name and DOB, what surg are you having, which side of the body? The pt or the RN marks with a pen the site of surgery

Intraoperative
Medications
Tourniquet time
Length of surgery
Personnel – surgeon [don’t keep pts alive, they make sure the surgical technique is good], anesthesiologist [keeps pt alive]. Surgical assistant, circulator [RN who’s not in the sterile field], scrub tech [hands scalpels, etc], Sometimes an extra tech is there; xray tech in orthoscopic
Types of anesthesia
general: inhaled; they’re paralyzed, no voluntary or involuntary movement; can’t breath for themselves. Also given IV pain meds
Monitored anesthesia care (MAC): anesthesiologists intubate pts, monitor vitals and sometimes stick an EKG on the head to monitor if pts are sedated enough—sometime pts aren’t deep enough and they are conscious but unable to move [scary!]
Regional or local
Conscious sedation

Post anesthesia care (PACU): airway is number one here. Want to assess VS, LOC, nueor type check. Pts itch, can’t pee, nauseous are cold, we give warm IV fluids, don’t release from PACU until they can move their legs a little b/c of fall risk.
a. Assessment: airway, respirations, 0² sat, HR, B/P, rhythm, LOC, protective reflexes, CSM, pulses, drains, surgical site, lines, orders, X-rays, labs, IV fluid, special monitoring, suction, etc.
b. Nursing interventions – elevate surgical site, comfort, ice chips, scratch, etc.
Potential postoperative complications- respiratory, circulatory, urinary, gastrointestinal, wound, psychologic.

Receiving a patient from surgery: get the room ready, equipment ready
Assess airway, do a head to toe assessment of patient. Have all equipment needed in the room (oxygen, suction, IV pump, etc.)
Vital signs every 15 minutes until stable, including oxygen saturation and pain. Docs order VS Q15 minutes for 1 hr, then Q30 minutes
What are the most common post-operative complications? Can’t pee, itchy, nauseous, etc.
Family-centered care.