perioperative nursing care pp


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  • -ectomy: removal -otomy: incision -plasty: change shape -oscopy: look
  • 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 pp

    1. 1. Perioperative Nursing Care
    2. 2. 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
    3. 3. II. Preoperative NursingAssessmentA. AgeB. AllergiesC. Vital sign trendD. Nutritional statusE. Habits affecting tolerance to anesthesia – drug & alcohol use – smoking: 6x risk increase
    4. 4. 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
    5. 5. 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.
    6. 6. Informed consent
    7. 7. 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.
    8. 8. Teaching splinting the incisionDuring TCDB, etc. to maintain incision integrity Teaching – PCA pump
    9. 9. 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
    10. 10. 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
    11. 11. Preoperative check list
    12. 12. 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
    13. 13. 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
    14. 14. • Preparation of a sterile fieldzSterile clothing is worn in the OR Preparation of a sterile field
    15. 15. An OR suite
    16. 16. C. Types of anesthesiaFactors to consider in anesthetics:• current health status and history• emotional stability• factors relating to operative procedure
    17. 17. 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
    18. 18. 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
    19. 19. 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
    20. 20. Spinal and Epidural Anesthesia
    21. 21. 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
    22. 22. Operative positions
    23. 23. 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%
    24. 24. 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
    25. 25. 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.
    26. 26. Post-operative position
    27. 27. Postoperative CarePreparing for post-operative patientInitial Assessment and InterventionsSelecting important data from chartGeneral post-op assessment & interventions
    28. 28. 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?
    29. 29. 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
    30. 30. 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
    31. 31. 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
    32. 32. Potential Postoperative Complications Hematological Respiratory Cardiovascular Urinary Gastrointestinal Neurological Immunological Wound Psychological
    33. 33. Potential Postoperative Complications HematologicalHemorrhage: S/S: External: Surgical site (dressing, drains, linens) Internal: tenderness, swelling B/P changes, CBC levels. Symptoms of hypovolemia
    34. 34. Potential Postoperative Complications RespiratoryAtelectasis: Collapse of alveoliPneumonia: Fluid infiltrationPulmonary embolism: DVT moved to lungPrevention: Deep breath, cough & Incentive spirometer, hydrations, antibiotics, anti-embolism interventions & Rxs
    35. 35. Postoperative Atelectasis
    36. 36. Potential Postoperative Complications Cardiovascular Hypotension: Hypovolemic: Hemorrhage,dehydration, due to NPO status, poor IV access Cardiac dysrhythmias: Due to dehydration, previous condition, anesthesia, electrolyte imbalance. Deep Vein Thrombosis Prevention: Assessment & intervention, hydration, continue previous meds.
    37. 37. Potential Postoperative Complications Thromboembolism: DVT/PE#1 cause of mortality in Post-op & Hospitalized patients 200,000-600,000 cases annually 60,000-200,000 die annually (APHA, 2003)
    38. 38. Potential Postoperative Complications Thromboembolism Continued…Causes: Dehydration,immobility, vascular manipulation or injury, hormones & birth control, history of DVTS/S: Redness, swelling, pain, chest pain, SOB, dyspneaPrevention: Turn, cough, deep breath, ROM, ambulation, hydration, exercises antiembolism & sequential stockings and anticoagulants
    39. 39. Assessing for Homan’s sign
    40. 40. Post-operative Leg Exercises
    41. 41. Potential Postoperative Complications Urinary Urinary retention: (bladder related) S/S: Tenderness, low or no output, distension, incontinence. Low urine output: (renal) < 30mL/hr rule Causes: Anesthesia, anticholinergic and narcotics, dehydration, position,ARF or CRF.
    42. 42. Palpation for bladder distention
    43. 43. Potential Postoperative Complications GastrointestinalParalytic ileus: Causes: Intestinal manipulation, narcotics, premature introduction of food Tx: NG tube to suction, NPOConstipation: Causes: Narcotics, NPO, dehydration, inactivity, previous hx. Tx: Hydration, ambulation, stool softeners and/or fiber.
    44. 44. Potential Postoperative Complications NeurologicalCVA or stroke: Causes: DVT Prevention: Same as DVT/PENarcosis or “narcotized state” Causes: Opiod Naïve, anesthesia, narcotic overload.Sensory changes: peripheral and urinary
    45. 45. Potential Postoperative Complications ImmunologicalInfection:Signs & Symptoms: Assessment: Fever, tenderness, redness, swelling, drainage color changes or c/o “feeling lousy.” Lab: Elevated WBCsPrevention: Aseptic technique when handling wounds, dressings and drains.
    46. 46. Jackson-Pratt Drain
    47. 47. Hemovac Drain
    48. 48. Cleaning a Drain Site Penrose drain
    49. 49. Cleaning a Wound Site
    50. 50. Montgomery Ties
    51. 51. Potential Postoperative Complications Wound Dehiscence: Spontaneous opening of incision Evisceration: Escape of Organs Infection: Invasion of organisms w/ potential of causing diseasePrevention: Hand washing, assessment, aseptictechnique, binder, splinting and patient teaching.
    52. 52. Dehiscence and Eviseration
    53. 53. Abdominal Binder
    54. 54. Splinting Methods
    55. 55. Surgical wound classifications
    56. 56. Potential Postoperative Complications Psychological:Body image Problems: Scarring, drains, amputation, ostomy.Pain Management: • Pre-op pain vs. post-op pain • Chronic pain vs. acute pain