Informed consent: active shared decision making process between provider and patient. Protects all involved. Responsibility of surgeon to have it signed. Contains anticipated procedures, other procedures that might need to be done, and anything that can happen to the patient, including death. Patient must be of legal age or parent/guardian responsible. Must be signed voluntarily, never through coercion.
Explain rationale, too.
Patients also can go home and die of DVT
Nursing care aimed at avoiding post-op complications
Perioperative Nursing Care
I. Types of SurgeryA. Diagnostic - determination of presence and/or extent of pathology, ex. lymph node biopsyB. Therapeutic - curative. Elimination/repair of pathology, ex. appendectomyC. Palliative - relieve or alleviate without curing, ex. g- tube placementD. Preventive - stop another problem from happening ex. suspicious moleE. Cosmetic - optional. Decision rests with patient.Other TypesEmergency - required immediately. May be life threateningElective - should operate, not catastrophic -ectomy: removal -otomy: incision -plasty: change shape -oscopy: look
II. Preoperative NursingAssessmentA. AgeB. AllergiesC. Vital sign trendD. Nutritional statusE. Habits affecting tolerance to anesthesia – drug & alcohol use – smoking: 6x risk increase
II. Preoperative Nursing AssessmentF. Presence of infectionsG. Use of drugs that are contraindicated prior to surgery Everything! Including OTC herbal supplements, etc.H. Physiological status / labs Full H&P by physicianI. Psychological state of the patient
III. Patient preparation A. Operative consent. Nurse is advocate. 3 conditions: • adequate disclosure of Dx, nature & purpose of Rx, risks & consequences • must demonstrate clear understanding & comprehension of information • must be given voluntarilyInformed consent: active shared decision making process between provider andpatient. Protects all involved. Responsibility of surgeon to have it signed.Contains anticipated procedures, other procedures that might need to be done, andanything that can happen to the patient, including death.Patient must be of legal age or parent/guardian responsible. Must be signedvoluntarily, never through coercion.
B. Preoperative learning needsIndividualized for pt’s needs.Common needs:• Deep breathing and coughing• Turning and active body movement• Pain control and medications – Educate pt. on notifying nurse if pain occurs.• Tubes, drains, dressings, other devices to expect (SEDs, TEDs, IS, etc.)• Cognitive control – psychosocial aspects. Explain rationale, too.
Teaching splinting the incisionDuring TCDB, etc. to maintain incision integrity Teaching – PCA pump
C. Interventions the day/evening priorto surgery• Intake restrictions – NPO after midnight – Although, evidence that pt. can have clear liquids up to 2 hours before surgery• Cleansing enema or laxative night before (bowel preps) – For purpose of preventing defecation during surgery, promoting intestinal deflation in case of surgical site local to bowels• Skin prep – Ex. hot shower before surgery & additional skin prep in OR
D. Interventions the day of surgery• NPO• May receive preanesthetic medication• Skin prep• Jewelry removed or taped – Defibrillation or cauterization will cause burns• Void right before going to surgery• Preoperative check list
IV. Intraoperative nursing considerationsA. Nursing roles1. Circulating RN - manages OR room. Nonsterile activities. Protects safety & health needs of patient by monitoring all activities of members of surgical team & conditions of OR.2. Scrub RN• Sterile activities• Scrub for surgery• Set up sterile table, prepare sutures, special equipment• Assist surgeon during procedure - anticipate needs• Ensure equipment/instrument count with circulating RN
B. Perioperative asepsis• Main priority of surgery - prevent patient problems• Includes protecting patient from infection1. All materials in sterile field must be sterile2. Sterile items in contact with non-sterile items are contaminated3. Remove contaminated items immediately4. Sterile team members wear sterile gowns5. Keep wide margin between sterile & non-sterile field6. Tables sterile only at tabletop level7. Edges of sterile package contaminated once package is opened8. Bacteria travel on airborne particles9. Bacteria travel by capillary action through moist fabrics11. Bacteria harbor on patients and team members’ hair, skin, and
• Preparation of a sterile fieldzSterile clothing is worn in the OR Preparation of a sterile field
C. Types of anesthesiaFactors to consider in anesthetics:• current health status and history• emotional stability• factors relating to operative procedure
C. Types of anesthesia• General - loss of sensation with loss of consciousness• Local - loss of sensation without loss of consciousness• Conscious sedation - minimally depressed LOC, twilight sleep• Regional - loss of sensation without loss of consciousness when specific nerve is blocked, ex. spinal anesthetic
1. General Anesthesia• IV Anesthesia Anesthesia induction• Inhalation Agents• Adjuncts to General Anesthesia – Muscle relaxation & reflex control – Relieve pain & anxiety – Amnesia, LOC• Begin with IV induction of short acting barbiturate
2. Regional Anesthesia• Suspends sensation in parts of body• Injected around nerves so area supplied by nerves is anesthetized• Effect depends on type of nerve involved• Spinal anesthesia• Epidural block
D. Patient positioningDepends on surgery & condition of pt.• correct skeletal alignment• undue pressure on nerves, skin over bony prominences, eyes• adequate thoracic excursion• occlusion of arteries and veins• modestly in exposure• recognize and respect individual needs
E. Temperature alterations during interoperative period May be intentional. May be caused by: • low temp in OR • infusion of cold fluid • inhalation of cold gases • open body wounds or cavities • decreased muscle activity • advanced age • drugs used (vasodilators)Malignant hyperthermia – hypermetabolic condition of very high temperaturesassociated with muscle rigidity in the skeletal muscles. Occurs in some peopleexposed to certain anesthetics. Can lead to cardiac dysrhythmia. Mortality rate >50%
V. Postoperative careA. Preparation for admitting the new postoperative patientsB. Initial assessment and interventions upon receiving the patientC. Selected data from the chart that is of importance
D. Post operative nursing assessment and concerns• Ineffective airway clearance• Pain & other postoperative discomforts• Risk for altered body temperature• Risk for injury related to postanesthesia• Altered nutrition – less than body requirements• Altered urinary elimination• Constipation• Impaired physical mobilityAnesthetic into body through inhalation, out through expiration. Encourage deepbreaths immediately to expel post-op.
Postoperative CarePreparing for post-operative patientInitial Assessment and InterventionsSelecting important data from chartGeneral post-op assessment & interventions
Preparing for Post-operative Patient Is there 02 in the room? IV or PCA pumps/poles? Pt arriving by bed or gurney? Does the patient need suction? Is traction required? Are tracheostomy supplies needed? Is the nurse’s assistant prepared?
Initial Assessment & Interventions LOC: Alert and oriented Comfort: Pain, nausea, pruritus Vital Signs: All especially respirations Wound: Incision Drains: Color, amount, location(s) Support equipment: Compression & Sequential stockings CPM PCA IV 02 NOTE: Nursing Care Plan Table 20-1 in LewisDressing: drainage, mark with pen and date to monitor for bleeding
Selecting Important Data from the Patient’s Chart Doctor’s orders History & Physical (H&P) Allergies Pre-op vital signs Pre-op medications Pre-op lab levels
General Post-opAssessment & Interventions Continue with initial Assessment then… Pain management Ambulate or ROM (per MD orders) Cough, deep breath & Incentive Spirometer Incisions and drains Antibiotic therapy Anti-DVT/PE interventions