Perioperative Nursing & Teaching

Carol J. McFadyen, RN, PhD

Modified by Sarah Jean Cooper RN, MN

Objectives – Student will be able to Describe legal requirements for informed

consent Identify risk factors for surgery Identify assessments and care needed

for surgical client Identify factors to consider in developing

a teaching plan Discuss the operative process

Objective 1: Concept of Perioperative Nursing

Covers all aspects of surgical care • Preoperative -Preparation for surgery

• Intraoperative -Surgery and recovery from anesthesia

• Postoperative-Recovery from surgery to discharge

Perioperative Nursing

Surgery classified by setting, urgency

– Table 49-1, p. 1208 shows classifications

Usually ambulatory and elective

Goal = provision of safe, effective care

Objective 2: Informed Consent

Legal Requirement for invasive procedure (Figure 17-1 in “Iggy”shows example)

– Surgeon provides information • Benefits • Risks• Alternatives

– Others only witness signature• Notify surgeon if client confused or needs more

information

Informed Consent

Special Considerations – Client with dementia – Minors– Implied Consent

• Life threatening • Telephone

Does not speak English

Objective 3: Preparation of Client for Surgery- AssessmentHealth History

– Screening for Risk Factors– Obtaining base line information

Physical Examination (Table 49-7 p1217)

Identify fears and concerns

Risk Factors Table 49-3, 49-4, p. 1214

Aging–Increases risk of other diseases

Medical Conditions –Respiratory and Cardiac most

criticalMedication Use

–List all medications used by client – Table 49-5 49-6, p. 1214

–Adverse reactions and interactions

Nursing Diagnosis

Anxiety • Use therapeutic communication to

elicit • Listen for experience with unusual

occurrence • Explain common occurrences and

procedures• Use a calm, unhurried approach

Nursing Diagnosis

Anticipatory Grieving • Listen for unusual concerns

Knowledge Deficit• Assess what client knows by asking him

to describe what he has been told and what previous surgical experiences he has had

Preoperative Preparation Laboratory/Diagnostic Studies - Box

49-2, p. 1218– Complete Blood Count (CBC)

• Hemoglobin and hematocrit (Hgb & Hct) – oxygen carrying capacity

• White blood cell count (WBC) – infection

– Clotting capacity• Prothrombin (PT) or partial thromboplastin

time (PTT)– Urinalysis – bladder & kidney

Preoperative Preparation

Laboratory and diagnostic studies (cont.)– Chest X-ray

• Respiratory status

– Electrocardiogram• Cardiac function

– Fasting Glucose Level• Diabetic

Preoperative Physical Preparation

NPO after midnight or for specific period • Inform client and remove pitcher • Post sign on door

Skin preparation • Shower with antibacterial soap• Shaving controversial (usually done in pre-op area)• Additional cleansing for some

Remove contact lenses, glasses, jewelry Void prior to preoperative medications

Preoperative Documentation

Preoperative Checklist (Box 49-4, p.1224, Figure 17-5 p 258 in “Iggy”

– Assessment & Vital Signs– Informed consent– Reports of diagnostic/laboratory tests – Medications given that AM– Procedures completed

Objective 4: Develop a plan for providing age appropriate pre-operative teaching

Prevention is an important nursing role and function

Early discharge to home requires client/family to possess knowledge for self-care management

Client has a right to receive understandable information

Age Appropriate TeachingNrsg Dx = Knowledge Deficit Common Learning Needs–Knowledge re:

– Events and sensations perioperatively• Use language client understands and can

comprehend

– Pain Management• Availability

– Physical Exercises and importance of completing• Turn, deep breathing, leg exercises

Factors Affecting Client Teaching Literacy level & Language spoken

– Reading level Level of Education

– Health knowledge & Beliefs Age & Developmental level Adult education

– Self directed – motivation– Practical, purposeful – readiness to learn

Factors that Inhibit Learning (Barriers) Pain, fatigue Acute illness Self image, perception Timing/environmental issues Cultural issues Language client does not understand

(jargon,spoken language, perceptual issues)

Teaching Plan –Outcome Oriented First assess current knowledge level Learning Objectives – describes the

intended result of learning– Performance, what will the client be

able to do?– Condition, when will the client be

able to do?– Criterion, how well will the client

perform

Teaching Methods

Active participation important– Discussion – keep it simple– Printed materials– AV presentations– Demonstration– Role playing – works well with children

One on One Group teaching Formal Class or Informal opportunity

Evaluation of Learning/Documentation Measurable criteria

– Client must do something to document learning

• “Identify symptoms to report”• “Describe cause of disease and prognosis”• “Return demonstration of skill/procedure”

Documentation – Specifics of what was taught– What client knows or can do

Teaching Activity Checklist

Perform Needs Assessment– Identify special needs– Determine preferred learning style– Establish readiness to learn

Establish priorities Identify goal

– Compose measurable objectives

Teaching Activity Checklist

Determine method of presentation– Identify required materials

Formulate plan Control distracting environmental

factors Establish a caring, concerned

atmosphere Evaluate effectiveness of teaching.

Was stated outcome achieved?

Group Activity Meet in groups of 4-5 and identify one

pre-operative or post-operative teaching need.

Identify how you would assess? Write a measurable goal/outcome. Develop a plan for teaching. Include

content (what will be taught) and method

State how you will know that learning has taken place

Objective 5: Discuss Medications administered during the Perioperative PeriodSedatives/hypnoticsAnticholinergicsH2 anatagonistsAntiemeticsAnalgesics

Sedatives/Hypnotics (Barbiturates & Benzodiazepines) Action: Depresses the CNS TE: Relief of anxiety,sedation,amnesia

– Potentiate action of opiod analgesics Interventions:

– Monitor vital signs especially Respiratory rate and BP

Evaluate : reduction in anxiety, drowsiness/resting

Examples: Valium, Ativan, Phenergan

Anticholenergics

Action: Inhibits action of acetylchloline at postganglionic sites located in smooth muscle, secretory glands, and the CNS

TE: Decreases GI & Respiratory secretions (prevents aspiration during surgery)

Interventions: Monitor Monitor VS, I&O and urinary output (may cause retention)

Evaluation: Decreased secretions in OR, client has dry mouth

Examples: Robinul, Atropine

Antiulcer Agents -H2 Antagonists Action: Inhibits gastric acid secretion TE: Decreased secretion of gastric acid Interventions: Monitor for complaints of

epigastric pain, in elderly watch for confusion, several drug interactions, timing of drug is important

Evaluation: decreased epigastric pain after eating

Examples: Ranitidine, Famotidine,Cimetidine

Antiemetics (Phenothiazines)

Action:Depresses the chemoreceptor trigger zone in the CNS

TE: Diminished nausea a & vomiting Interventions: Give deep IM, slowly.

Assess VS and for drowsiness. May cause decreased BP on standing

Evaluation: Decreased nausea and vomiting

Antiemetics – Reglan (Metoclopaminde)

Action:Blocks dopamine receptors in chemoreceptor trigger zone of the CNS. Stimulates motility of upper GI tract and gastric emptying

TE: Decreased nausea & vomiting Interventions: Give before meals (30min)

monitor for excessive drowsiness, extrapyramidal symptoms

Evaluation: decreased nausea and/or vomiting

Opiod analgesics (may be

combined with ASA or Tylenol) Action:Bind to CNS receptors. Alters perception

of and response to painful stimuli while producing generalized CNS depression

TE: Decrease in severity of moderate pain Interventions: Assess VS (P&R), level of

sedation, Administer on regular basis for best pain relief. Give before pain becomes severe. Constipation is frequent side effect

Evaluation: Relief of pain (<3/10) Examples: Lortab, Vicodin, Percodan,Perocet

Objective 6: Describe the role of team members during surgery

Team members (Figure 18-5,6 in Iggy)

– Sterile = wear gown, gloves plus cap, mask• Surgeon – Responsible for client during surgery• Assistant – may be specially trained registered nurse• Scrub Technician – passes instruments, monitors sterility

– Unsterile = wears cap and mask• Circulating Nurse – coordinates care (Figure 18-3

shows)• Anesthesiologist/CRNA = Monitors client status

Objective 7: Health Promotion and Prevention during Surgery Risk for Perioperative positioning

injury• Figure 49-7, p. 1229 shows positions • Loss of pain sensation

– Pad pressure points – Avoid pressure on nerves

• Assess skin integrity before and after• Maintain anatomic position of joints

– Involuntary movements may increase stress

Measures to Maintain Health-Intraoperative Care Risk for Injury

– Falls• Side rails up • Belts • Teach to not get up post medication

– Burns • Proper grounding of equipment

– Retained foreign objects • Accurate sponge counts

Intraoperative Care- Measures to Maintain Health Risk for Infection

– Caps, mask, clothing– Skin Preparation – Draping – Surgical asepsis maintained

Types of Anesthesia

General -Medication given by Intravenous or inhalation routes

– Can be used for all ages and surgeries – Intravenous for Induction – May be given in SDS for young child

– Agents rapidly excreted and action reversed

– Causes cardiac and respiratory depression

Types of Anesthesia Anesthesia = partial or complete loss of sensation

with or without loss of consciousness– Local –used for small areas – infiltration or topical– Regional – several types

• Medication instilled around or into the nerves blocks nerve transmission (Figure 49-2, p. 1212)

• Client awake during procedure, does not perceive pain

• Disadvantages = hypotension, spinal headache

Intraoperative Care Types of Anesthesia

– Concious Sedation• Used for diagnostic procedures • Medication given by IV push

– Midazolan hydrochloride (Versed)– Meperidine given for analgesia

• Nurse monitors client – Airway, vital signs, O2 Saturation

• Client sleepy but arouses – Does not remember details of procedure

Four Phases of Anesthesia (See

Table 18-2, p 270 “Iggy”)

Stage 1 Induction to loss of consciousness – vulnerable to noise

Stage 2 Excitement -starts with loss of consciousness and ends with loss of eyelid reflex – vulnerable to noise & injury

Stage 3 Operative – relaxation to loss of hearing, sensation to pain lost

Stage 4 Extreme depression of functions leads to death if not reversed

Anesthetic Agents (Table 18-3 & 18-4 p271-

72 “Iggy”

Agents used are dependent on client’s physical condition and nature of surgery(Length of procedure, age of client etc)

PACU & OR RN’s must be knowledgeable about side effects of each agent used in anesthesia in order to protect the client and assist in recovery

Objective 8: Describe Assessments to Identify and Respond to Potential Anesthesia Complications (PACU)

Monitored by PACU RN– Airway, may have laryngospasm when

extubated

– Vital Signs – LOC – respond to command or stimuli– Bleeding– Pain

Objective 9: Develop a nursing care plan to restore health for the post surgical client Postoperative assessment for Complications

– Impaired Gas Exchange/Ineffective Breathing Pattern

– Risk for Infection– Fluid Volume Deficit– Alteration in Nutrition:Less than body

requirements (nausea & vomiting, NPO)– Alteration in Elimination– Pain– Altered Tissue Perfusion – Risk for injury/Body Image Disturbance

Focused Assessment of Post-operative Client Immediate post-op client on unit

– Airway (patent, O2??, breath sounds Resp)– Cardiovascular (BP, Pulse & Temp)– LOC (establish)– Dressings, Tubes/drains (check)– IV fluids/status (rate, solution, site)– Skin Integrity & positioning (condition)– Comfort Level (pain, nausea, last med)– Safety – side rails, call light– New orders

Focused Post Surgery Shift Assessment Activity Form into groups of 4-5 Draw a picture of assigned client or

problem Identify assessments and rationale for

assessments for the client Identify interventions/rationale to prevent

complications, promote health Report to class

Postoperative Care

Special Considerations – Elderly

• Recovery slower – Interventions to prevent complications need

to be scrupulous• May be more sensitive to medications

– Confusion – Respiratory depression

• Monitor closely for post op infection

Postoperative Care

Special Considerations – Children– Use of FACES scale for assessment of pain

• Watch for non verbal behaviors indicating pain in younger

• Medicate prior to painful procedures – Encourage parents to stay with child/assist with care

• Be sure security objects available– Illness/hospitalization may result in < coping

• Provide age appropriate diversion– Explain procedures to child in age appropriate terms

• Prepare child if procedure hurts • Praise for accomplishments