Perioperative client

By I.KORDA

Perioperative period

PreoperativeIntraoperativePostoperative

Care of preoperative client

Education

Preoperative procedures

Purposes of surgery

DiagnosticCurativeRestorativePalliativeCosmetic

Urgency

Elective

Urgent

Emergent

Emergent—Patient requires immediate attention

Disorder may be life-threatening

Without delaySevere bleedingBladder or intestinal obstructionFractured skullGunshot or stab woundsExtensive burns

Urgent—Patient requires prompt attention

Within 24–30 hAcute gallbladder infectionKidney or ureteral stones

Required—Patient needs to have surgery

Plan within a few weeks or monthsProstatic hyperplasia without bladder

obstructionThyroid disordersCataracts

Elective—Patient should have surgery

Failure to have surgery not catastrophicRepair of scarsSimple herniaVaginal repair

Optional—Decision rests with patient

Personal preferenceCosmetic surgery

Degree of risk Minor Major

Category by location

Abdominal

Intracranial

Heart etc.

Ambulatory care centers and physician offices are the usual settings for minor surgical procedures.

Outpatient surgery areas (one-day surgery centers or free-standing ambulatory clinics) provide the client and physician with alternative services for urgent and elective surgeries.

Surgical settings

Perioperative Management of Care

Surgeon responsibilitiesDetermine the need for the surgical

intervention.Determine the surgical setting in

collaboration with the client.Order diagnostic tests.

Obtain client’s consent for the surgical procedure.

Teach the client about the outcomes and risks of the procedure.

Explain and document evidence that the client understands the nature of the surgical procedure, the risk factors, and expected outcomes of the surgery.

Criteria for Valid Informed Consent

Voluntary Consent Explanation of procedure and its risks Description of benefits and alternatives An offer to answer questions about procedure Instructions that the patient may withdraw

consent A statement informing the patient if the protocol

differs from customary procedure

• Invasive procedures, such as a surgical incision, a biopsy, a cystoscopy, or paracentesis

• Procedures requiring sedation and/or anesthesia

• A nonsurgical procedure, such as an arteriography, that carries more than slight risk to the patient

• Procedures involving radiation

Anesthesia provider responsibilitiesObtain informed consent for anesthesia.Perform a preanesthesia evaluation that

includes a thorough history.Select anesthetic agents.Teach the client regarding the anesthetic

medications, their side effects, and risk factors.

Perform intubation (the insertion of an endotracheal tube into the bronchus through the nose or mouth to ensure an airway)

and extubation (the removal of an endotracheal tube).

Nurse responsibilitiesSchedule the diagnostic tests.Verify that all the necessary

documents are on the client’s medical record.

Report abnormal diagnostic results to the surgeon.

Prepare and teach the client.

Collaborative management

History Physical assessment Psychosocial assessment Laboratory assessment Radiographic assessment Other diagnostic assessment

Collaborative Management Assessment

History and data collectionAgeDrugs and substance useMedical history, including cardiac and

pulmonary historiesPrevious surgery and anesthesiaBlood donationsDischarge planning

Physical Assessment/Clinical Manifestations

Obtain baseline vital signs. Focus on problem areas identified by the

client’s history on all body systems affected by the surgical procedure.

Report any abnormal assessment findings to the surgeon and to anesthesiology personnel.

System Assessment

Cardiovascular system Respiratory system Renal/urinary system Neurologic system Musculoskeletal system Nutritional status Psychosocial assessment

Laboratory Assessment Urinalysis Blood type and crossmatch Complete blood count or hemoglobin level

and hematocrit Clotting studies Electrolyte levels Serum creatinine level Pregnancy test Chest x-ray examination Electrocardiogram

Deficient Knowledge Interventions

Preoperative teaching Informed consent

The surgeon is responsible for obtaining signed consent before sedation is given and surgery is performed.

The nurse’s role is to clarify facts presented by the physician and dispel myths that the client or family may have about surgery.

Implementing Dietary Restrictions

Client is given nothing by mouth (NPO) for 6 to 8 hours before surgery.

NPO status decreases the risk for aspiration.

Failure to adhere can result in cancellation of surgery or increase the risk for aspiration during or after surgery.

Administering Regularly Scheduled Medications

Consult the medical physician and anesthesia provider for instructions about drugs, such as those taken for diabetes, cardiac disease, glaucoma, regularly scheduled anticonvulsants, antihypertensives, anticoagulants, antidepressants, or corticosteroids.

Intestinal Preparation

Bowel or intestinal preparations are performed to prevent injury to the colon and to reduce the number of intestinal bacteria.

Enema or laxative may be ordered by the physician.

Skin Preparation

The skin is the body’s first line of defense against infection; a break in the barrier increases the risk for infection.

Shower using antiseptic solution. Shaving as a procedure before surgery is

viewed as controversial.

Preparing the Client

Possible placement of tubes, drains, and vascular access devices

Teaching about postoperative procedures and exercises:Breathing exercises, incentive spirometry, coughing

and splinting

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Preparing the Client (Continued)

Leg procedures and exercises, antiembolism stockings and elastic wraps, early ambulation, and range-of-motion exercises

Anxiety Interventions

Preoperative teaching Encouraging communication Promoting rest Using distraction Teaching family and significant others

Preoperative Chart Review

Ensure all documentation, preoperative procedures, and orders are complete.

Check the surgical consent form and others for completeness.

Document allergies. Document height and weight.

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Preoperative Chart Review

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Ensure results of all laboratory and diagnostic tests are on the chart.

Document and report any abnormal results.

Report special needs and concerns.

Preop Client Prep

Client should remove most clothing and wear a hospital gown.

Valuables should remain with family member or be locked up.

Tape rings in place if they can’t be removed. Remove all pierced jewelry.

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Preop Client Prep (Continued)

Client wears an identification band. Dentures, prosthetic devices, hearing aids,

contact lenses, fingernail polish, and artificial nails must be removed.

Preoperative Medication

Reduce anxiety. Promote relaxation. Reduce pharyngeal secretions. Prevent laryngospasm. Inhibit gastric secretion. Decrease amount of anesthetic needed for

induction and maintenance of anesthesia.

Interventions for Intraoperative

Clients

Members of the Surgical Team

Surgeon Surgical assistant Anesthesiologist Certified registered nurse anesthetist Holding area nurse Circulating nurse Scrub nurse Surgical technologist Operating room technician

Environment of the Operating Room

Preparation of the surgical suite and team safety

Layout Health and hygiene of the surgical team Surgical attire Surgical scrub

Anesthesia

Induced state of partial or total loss of sensation, occurring with or without loss of consciousness

Used to block nerve impulse transmission, suppress reflexes, promote muscle relaxation, and, in some instances, achieve a controlled level of unconsciousness

General Anesthesia Reversible loss of consciousness is induced

by inhibiting neuronal impulses in several areas of the central nervous system.

State can be achieved by a single agent or a combination of agents.

Central nervous system is depressed, resulting in analgesia, amnesia, and unconsciousness, with loss of muscle tone and reflexes.

Stages of General Anesthesia

Stage 1: analgesia Stage 2: excitement Stage 3: operative Stage 4: danger

Administration of General Anesthesia

Inhalation: intake and excretion of anesthetic gas or vapor to the lungs through a mask

Intravenous injection: barbiturates, ketamine, and propofol through the blood

Adjuncts to general anesthetic agents: hypnotics, opioid analgesics, neuromuscular blocking agents

Balanced Anesthesia

Combination of intravenous drugs and inhalation agents used to obtain specific effects

Combination used to provide hypnosis, amnesia, analgesia, muscle relaxation, and reduced reflexes with minimal disturbance of physiologic function

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Balanced Anesthesia

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Example: thiopental for induction, nitrous oxide for amnesia, morphine for analgesia, and pancuronium for muscle relaxation

Complications from General Anesthesia

Malignant hyperthermia: possible treatment with dantrolene

Overdose Unrecognized hypoventilation Complications of specific anesthetic

agents Complications of intubation

Local or Regional Anesthesia Sensory nerve impulse transmission from a

specific body area or region is briefly disrupted.

Motor function may be affected. Client remains conscious and able to follow

instructions. Gag and cough reflexes remain intact. Sedatives, opioid analgesics, or hypnotics are

often used as supplements to reduce anxiety.

Local Anesthesia

Topical anesthesia Local infiltration Regional anesthesia

Field blockNerve blockSpinal anesthesiaEpidural anesthesia

Complications of Local or Regional Anesthesia

Anaphylaxis Incorrect delivery technique Systemic absorption Overdosage

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Complications of Local or Regional Anesthesia

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Assess for central nervous system stimulation, central nervous system and cardiac depression, restlessness, excitement, incoherent speech, headache, blurred vision, metallic taste, nausea and vomiting, tremors, seizures, increased pulse, respirations, and blood pressure.

Treatment of Complications Establish an open airway. Give oxygen. Notify the surgeon. Fast-acting barbiturate is usual treatment. If toxic reaction is untreated,

unconsciousness, hypotension, apnea, cardiac arrest, and death may result.

Conscious Sedation

IV delivery of sedative, hypnotic, and opioid drugs reduces the level of consciousness but allows the client to maintain a patent airway and to respond to verbal commands.

Diazepam, midazolam, meperidine, fentanyl, alfentanil, and morphine sulphate are the most commonly used drugs.

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Conscious Sedation (Continued)

Nursing assessment of airway, level of consciousness, oxygen saturation, electrocardiographic status, and vital signs are monitored every 15 to 30 minutes.

Collaborative Management

Assessment Medical record review Allergies and previous reactions to anesthesia

or transfusions Autologous blood transfusion Laboratory and diagnostic test results Medical history and physical examination

findings

Risk for Perioperative Positioning Injury

Interventions include: Proper body position Risk for pressure ulcer formation Prevention of obstruction of circulation,

respiration, and nerve conduction

Impaired Skin Integrity and Impaired Tissue Integrity

Interventions include: Plastic adhesive drape Skin closures, sutures and staples,

nonabsorbable sutures Insertion of drains Application of dressing Transfer of client from the operating room table

to a stretcher

Potential for Hypoventilation

Continuous monitoring of:BreathingCirculationCardiac rhythmsBlood pressure and heart rate

Continuous presence of an anesthesia provider

Interventions for Postoperative

Clients

PACU Recovery Room

Purpose is to provide ongoing evaluation and stabilization of clients to anticipate, prevent, and treat complications after surgery.

PACU is usually located close to the surgical suite.

The PACU nurse is skilled in the care of clients with multiple medical and surgical problems that can occur following a surgical procedure.

Collaborative Management

Assessment Physical assessment and clinical

manifestations Assess respiration. Examine surgical area for bleeding Monitor vital signs. Assess for readiness to discharge once

criteria have been met.

Respiratory System

Airway assessment Breath sounds Other respiratory assessments

Cardiovascular Assessment

Vital signs Cardiac monitoring Peripheral vascular assessment

Neurologic System

Cerebral functioning Motor and sensory assessment important

after epidural or spinal anesthesiaMotor function: simple commands; client to

move extremitiesReturn of sympathetic nervous system tone:

gradually elevate head and monitor for hypotension

Fluid, Electrolyte, and Acid-Base Balance

Check fluid and electrolyte balance. Make hydration assessment. Intravenous fluid intake should be

recorded. Assess acid-base balance.

Renal/Urinary System

The effects of drugs, anesthetic agents, or manipulation during surgery can cause urine retention.

Assess for bladder distention. Consider other sources of output such as

sweat, vomitus, or diarrhea stools. Report a urine output of < 30 mL/hr.

Gastrointestinal System Nausea and vomiting are common reactions

after surgery. Peristalsis may be delayed because of long

anesthesia time, the amount of bowel handling during surgery, and opioid analgesic use.

Clients who have abdominal surgery often have decreased peristalsis for at least 24 hours.

Nasogastric Tube Drainage

Tube may be inserted during surgery to decompress and drain the stomach, to promote gastrointestinal rest, to allow the lower gastrointestinal tract to heal, to provide an enteral feeding route, to monitor any gastric bleeding, and to prevent intestinal obstruction.

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Nasogastric Tube Drainage

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Assess drained material every 8 hours. Do not move or irrigate the tube after

gastric surgery without an order from the surgeon.

Skin Assessment

Normal wound healing Ineffective wound healing: can be seen most

often between the 5th and 10th days after surgeryDehiscence: a partial or complete separation of

the outer wound layers, sometimes described as a “splitting open of the wound.”

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Skin Assessment (Continued)

Evisceration: a total separation of all wound layers and protrusion of internal organs through the open wound.

Dressings and drains, including casts and plastic bandages, must be assessed for bleeding or other drainage on admission to the PACU and hourly thereafter.

Discomfort/Pain Assessment

Client almost always has pain or discomfort after surgery.

Pain assessment is started by the postanesthesia care unit nurse.

Pain usually reaches its peak the second day after surgery, when the client is more awake, more active, and the anesthetic agents and drugs given during surgery have been excreted.

Impaired Gas ExchangeInterventions include: Airway maintenance Positioning the client in a side-lying

position or turning his or her head to the side to prevent aspiration

Encouraging breathing exercises Encouraging mobilization as soon as

possible to help remove secretions and promote lung expansion

Impaired Skin IntegrityInterventions include: Nursing assessment of the surgical area Dressings: first dressing change usually

performed by surgeon Drains: provide an exit route for air, blood,

and bile as well as help prevent deep infections and abscess formation during healing

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Impaired Skin Integrity (Continued)

Drug therapy including antibiotics and irrigations are used to treat wound infection.

Surgical management is required for wound opening.

Acute Pain

Interventions include: Drug therapy Complementary and alternative therapies

such as:PositioningMassageRelaxation and diversion techniques

Potential for Hypoxemia

Interventions include: Maintenance of airway patency and

breathing pattern Prevention of hypothermia Maintenance of oxygen therapy as

prescribed

The classic signs of shock are:

• Pallor• Cool, moist skin• Rapid breathing• Cyanosis of the lips, gums, and tongue• Rapid, weak, thready pulse• Decreasing pulse pressure• Low blood pressure and concentrated urine

Patient’s readiness for discharge from the PACU

• Stable vital signs• Orientation to person, place, events, and time• Uncompromised pulmonary function• Pulse oximetry readings indicating adequate

blood oxygen saturation• Urine output at least 30 mL/h• Nausea and vomiting absent or under control• Minimal pain

Health Teaching

Prevention of infection Dressing care Nutrition Pain medication management Progressive increase in activity level Use of proper body mechanics

The end