Medical-Surgical Nursing Perioperative NursingNURSING CARE OF THE SURGICAL CLIENTANGEL ALBERT F. LAMBAN, RN, MD
Surgery• The treatment of injury, disease, or deformity through invasive operative methods.• Surgery is a unique experience, with no two clients responding alike to similar operations.
Surgery• Minor: Presenting little risk to life.• Major: Possibly involving risk to life.
From a Client’s Vantage Point• Surgery is a major stressor for all clients.• Anxiety and fear are normal.• Fear of the unknown is the most prevalent fear prior to surgery and is the fear that is the easiest for the nurse to help the client overcome.
Perioperative Nursing• Has one continuous goal: to provide a standard of excellence in the care of the client before, during, and after surgery.• Perioperative nursing is client oriented and must be geared to meet the client’s psychosocial needs as well as immediate physical needs.
Preoperative Phase: Common Anxieties• Fear of the unknown.• Fear of pain and discomfort.• Fear of mutilation and disfigurement.• Fear of anesthesia.• Fear of disruption of life patterns (separation from family and significant others; impact on sexual and financial situation)• Fear of death/not waking up.• Fear of not being in control.
Preoperative Physiologic Assessment• The outcome of surgical treatment is tremendously enhanced by accurate preoperative nursing assessment and careful preoperative preparation.• Information gathered through preoperative assessment and risk screening is later used for preparation of the surgical site, for surgical positioning, and as a comparative basis for postoperative assessments and complication screening.
Common Preoperative Laboratory Tests• Hemoglobin and • Prothrombin time (PT) hematocrit (Hgb and and partial Hct) thromboplastin time• White blood cell count (PTT) (WBC) • Bilirubin• Blood typing and • Liver enzymes cross matching • Urine analysis (screening) • Blood urea nitrogen• Serum electrolytes (BUN) and creatinine
Variables Affecting Surgical Status• Age • Cardiovascular status• Nutritional status • Renal and hepatic• Fluid and electrolyte status status • Neurological,• Respiratory status musculoskeletal, and• Medications integumentary status • Endocrine and immunological status
Client’s Psychological Condition• The psychological condition of a client can have a stronger influence than does the physical condition.• Encourage clients to express their feelings and fears about receiving anesthetic and having surgery.• Observe the client for nonverbal clues indicative of anxiety.• To reduce client anxiety, explain to client what will be happening throughout the surgical experience.
Psychosocial Health Assessment• Cultural beliefs can influence a person’s perception of surgery.• Clients should be provided the opportunity to express their spiritual values and beliefs.
Informed Consent• A legal form signed by the client and witnessed by another person that grants permission to the client’s physician to perform the procedure described by the physician.
Informed Consent is RequiredWHEN:• Anesthesia is used.• Procedure is considered invasive.• Procedure is nonsurgical but has more than a slight risk of complications.• When radiation or cobalt therapy is used.
Purposes of Preoperative Teaching• To answer questions and concerns about surgery.• To ascertain client’s present knowledge of the intended surgery.• To ascertain the need or desire for additional information.• To provide information in a manner most conducive to learning.
Physical Preparation• Identifying the client and verifying the operative procedure.• Preparing operative site.• Checking client’s vital signs.• Assisting in putting on hospital gown, cap, and, if ordered, antiembolic hose.• Verifying allergies.• Verifying NPO (nothing by mouth) status.• Identifying any sensory deficits in the client.
Members of Sterile Surgical Team• Surgeon.• First assistant (Physician or RN who assists surgeon in performing hemostasis, tissue retraction, and wound closure).• Scrub nurse (an LP/VN, RN, or surgical technologist who prepares and maintains integrity, safety, and efficiency of the sterile field throughout the operation).
Sterile Field• The area surrounding the client and the surgical site that is free from all microorganisms.
Non-Sterile Members of the Surgical Team• Anesthesia provider.• Circulating nurse (an RN responsible for management of personnel, equipment, supplies, environment, and communication throughout a surgical procedure).
Asepsis• The absence of pathogenic microorganisms.
Elements of Aseptic Technique• Sterile gowns and gloves.• Sterile drapes used to create sterile field.• Sterilization of items used in sterile field.
Sterile Conscience• The practice of aseptic technique requires the development of sterile conscience, an individual’s personal honesty and integrity with regard to adherence to the principles of aseptic technique.
Intraoperative Nursing Care Nurses are responsible for managing six areas of risk:• Risk of infection related • Risk for injury related to to invasive procedure chemical, physical, and and exposure to electrical hazards. pathogens. • Risk for impaired tissue• Risk for injury related to integrity. positioning during • Risk for alteration in fluid surgery. and electrolyte balance• Risk of injury related to related to abnormal blood foreign objects loss and NPO status. inadvertently left in the wound.
Postoperative Nursing Care Nurses are responsible for managing seven areas of risk:• Risk for ineffective • Risk for fluid volume airway clearance. deficit.• Risk for ineffective • Risk for breathing pattern. sensory/perceptual• Risk for aspiration. alterations.• Risk for decreased • Risk for injury and for cardiac output. altered thought processes.
Aldrete Score: Defined as:• A means of objectively assessing the physical status of clients recovering from anesthesia. Also known as the Post- Anesthetic Recovery Score.
Later Postoperative Nursing Care Nurses are responsible for managing these risks and complications:• Risk for ineffective airway • Risk for altered nutrition--less clearance caused by than body requirements atelectasis and hypostatic related to nausea and pneumonia. vomiting, abdominal• Risk for peripheral distension, constipation and neurovascular dysfunction, NPO status. fluid volume excess/deficit, • Risk for urinary retention. and activity intolerance. • Risk for sensory perceptual• Risk for anxiety or ineffective alterations. individual coping. • Risk for impaired skin integrity and infection due to surgical incision.
Ambulatory Surgery• Surgical care performed under general, regional, or local anesthesia and involving fewer than 24 hours of hospitalization.• Also known as same-day, one-day, outpatient, or short-stay surgery.• Cost containment, governmental changes, and technological advances have all promoted concept of ambulatory surgery.
Surgery and the Elderly• Because of the physiologic changes and complex needs of the elderly client undergoing surgery, the nurse must be knowledgeable in promoting health and rehabilitation in the elderly surgical client.
What is Perioperative Nursing?• Three Phases:• Preoperative (Preop)• Intraoperative (Intraop)• Postoperative (Postop)
Preoperative Phase• Begins when the client is scheduled for surgery and ends at the time of transfer to the surgical suite• 3-6 months• 30 days• 7 days• Day before
Intraoperative Phase• Transfer onto the operating table• Phases of anesthesia• Operative proceedure• Transfer from operating table to stretcher• Safe transport to post-operative area (PACU)
Nursing Process in Pre-op Phase• Assessment: Lab Data• Blood tests• Urine tests• Chest x-ray• EKG
Nursing Process in Pre-op Phase• Planning:• Correction of any abnormal labs• Blood donations• Bloodless surgery• Nutrition• Pain Management• Surgery Classes• Discharge planning
Nursing Process Pre-op Phase• Implementation:• Explain purpose of planned procedure• Asking questions• Adhering to NPO status• Stating understanding of preop preparations• Demonstrating correct use of exercises/techniques to prevent complications
Preoperative Client Preparation• Clothing removed/don patient gown• Jewelry removed including body any piercing• Prosthesis: dentures, wigs, limbs• Aides: hearing, glasses, cane• Arm bands: identification, code status, blood bracelet, fall risk status bracelet• Misc: contact lenses, hairpins• Nail polish, artificial nails
Preoperative Client Preparation• Empty bladder• Pre-operative medications• Safe transfer to surgical suite
Special Considerations• Patient’s age• Cognition• Ethnic• Language
Nursing Process in Preop Phase• Evaluation:• Safety• Health promotion & maintenance• Psychosocial integrity• Physiological Integrity
Nursing Diagnosis• Deficient knowledge r/t lack of exposure• Anxiety r/t threat of a change in health status or fear of unknown• Disturbed sleep patterns r/t internal sensory alteration (illness & anxiety)• Ineffective coping r/t impending surgery• Disturbed body image r/t anticipated changes
Nursing Diagnosis• Disabled family coping r/t temporary family disorganization and role changes• Powerlessness r/t health care environment, loss of independence and loss of control of one’s body
The Pediatric Client Read Wong!• Know guidelines for preparing children for procedures• What are non-threatening words?• How do children best learn? (think growth & development)• Stress points for the surgical experience include admission, blood test, time before surgery, injection of pre-op med, transport to & from OR & return from PACU. What can be done? – See nursing care plan in Wong
Collaborative Management: Assessment & Planning• Client interview – Correct person for the correct procedure with correct preparation on the correct anatomy• Risk for perioperative positioning injury – Lacks normal defense mechanisms – Size, age skin integrity• Potential for hypoventilation• Potential for hemodynamic shifts – Blood loss
Intraoperative Phase• Begins when the client enters into the surgical suite – Sedated? – Aware? – Noises – Cold – Double teamed
Types of Surgery• Elective-well planned• Urgent-limited planning• Emergent-no planning
Medical-Surgical Nursing: AnIntegrated Approach, 2E Anesthesia 15 Chapter
Anasthesia & AnalgesiaEssential to healthcare delivery today.• Anasthesia – absence of normal sensation• Analgesia – pain relief without anasthesia
Preanesthetic Preparation• Avoidance of foods and drink prevents passive regurgitation of gastric contents• Clients should typically continue medications up to surgery• Consent must be received
Sedation• Reduction of stress, excitement, or irritability and some suppression of CNS• Typically used to relieve anxiety and discomfort during a procedure• Residual effects include amnesia and letheragy
Regional Anesthesia• A region of the body is rendered insensible to pain.
Residual Effects• Motor Block• Sensory Block• Sympathetic Block
General Anesthesia• Involves unconsciousness and complete insensibility to pain• There are four stages of General Anesthesia: – Induction – Maintenance – Emergence – Recovery
Induction & Airway Management• Shortest stage of Anesthesia but critical• Immediately after induction, the airway must be secured using a cuffed Endotracheal tube (ETT)
Maintenence• General Anesthesia is maintained with a combination of IV and inhaled drugs• Sometimes specialized medicines are applied to achieve complete paralysis, relax skeletal muscles and more
Emergence• Client’s awareness returns as drug wears off• Emergence must be carefully controlled and monitored
Recovery• Recovery may be an extended process with memory and other aspects affected for a long period• Many anesthetics are absorbed into body fat and released slowly into the system
Common Concerns• Client may suffer from apnea, decline in respirations• Few direct heart rate and blood pressure effects, but these should be closely monitored• Client may have trouble regulating body temperature• Client may have abnormal fluid levels
Post Operative Pain Management• Post-Operative pain results from: – Tissue injury – Inflammation – Hormonal changes – Hyperexcitability and more
Methods for Controlling Pain• Patient Controlled Analgesia• Regional Analgesia – Local anasthetics – Opioids
Anesthesia: more choices and alternatives• General Anesthesia• Regional Anesthesia• Intravenous Anesthesia• Local Anesthesia• Balanced Anesthesia
General Anesthesia• Inhalation-Mask, Endotracheal tube (ETT) or Laryngeal managed airway (LMA)• Intravenous• Combination
General Anesthesia: Inhalation Agents• Inhalation most controllable method; lungs act as passageway for entrance & exit of agent• Gas Agents : Nitrous Oxide – must be given with oxygen – require assisted to mechanical ventilation – frequently shiver – taken in & excreted via lungs – Examples: halothane, enthrane, florane…
Stages of General Anesthesia See Table 18-2, p. 270• Stage 1: Analgesia/Sedation/Relaxation• Stage 2: Excitement/Delirium• Stage 3: Operative Anesthesia• (Stage 4: DANGER: BAD) not expected/normal• Speed of EMERGENCE (recovery from anesthesia) depends on type of anesthesia, length of time & many other factors- try to time with end of surgery
General Anesthesia: Intravenous• Intravenous Agents – Thiopental Sodium (Pentothal) but is commonly called “Sodium Pentothal” by patients (class: barbiturate) – Diprovan (Propofol-Milk of Amnesia) – rapid acting – monitor vital signs – respiratory depression
Adjuncts to General Anesthesia• Hypnotics (Versed, Valium) – also used for conscious sedation• Opioid Analgesics (morphine, Demerol) – respiratory depression• Neuromuscular Blocking Agents – Causes muscle paralysis – Examples: Pavulon, Succinycholine – What vital function is affected?
Balanced Anesthesia (a sample)• Start with Pentothal or Propofol• Add in some nitrous oxide for amnesia• Use inhalation agent such as halothane• Stir in a little opiate- morphine, fentenyl, for postop analgesia• To top it off give Pavulon, a neuromuscular blocker, for additional muscular relaxation
Potential General Anesthesia Complications • Overdose (consider risk factors) • Hypoventilation postoperatively • Intubation related: sore throat, hoarseness, broken teeth, vocal cord trauma • MALIGNANT HYPERTHERMIA – Genetic predisposition – Triggered by anesthetics such as Halothane
Regional Anesthesia• Loss of sensory nerve impulses; motor function may or may not be affected – No loss of consciousness• Field Block: “caine” injected around a nerve or group of nerves (dental procedures) – May be combined with epinephrine to prolong – Approximately 30 min to 2 hours
Regional Anesthesia: Spinal• Local anesthetic (-caine) injected into cerebrospinal fluid (approx L 3-5) subarachnoid space
Spinal Anesthesia (Subarachnoid Block)• Anesthesia: tip of xiphoid to toes• Risks: – Loss of vasomotor tone – “Spinal Headache” – Infection, Rising anesthesia above diaphragm• Nursing: KEEP FLAT, MONITOR VS & OFFER FLUIDS WHEN APPROPRIATE
Regional Anesthesia: Epidural• Injected into epidural space rather than subarachnoid fluid (usually safer)• Used for OR & OB• Epidural catheter can be left in place for postop pain management (PCA)
Conscious Sedation• Reduce intensity of pain without loss of defensive reflexes• Usually a combination of opioid analgesic and sedative-hypnotics• May be administered by credentialed RN• Expect client to be sleepy but arousable• JUST BECAUSE HIS EYES ARE CLOSED DOESN’T MEAN HE’S ASLEEP!!
Local Anesthesia• Local/Topical – Interrupts transmission of sensory nerve impulses so it: numbs what it touches – Requires multiple injections with “CAINE” drug (Example: novacaine, lidocaine) – Duration = 1 min to 20-30 min -Can be prolonged with added epinephrine
Nursing Process Intraop Phase• Evaluation – Expected – Unexpected – Documented – Informing Client & Family – Surgical Waiting Room – Ongoing Updates by OR Team
Altered Skin Integrity• How many sutures?• Staples or sutures or glue???
Postoperative Goals• Re-establishment of physiologic equilibrium• Alleviation of pain• Prevention of complications
Immediate Post-anesthesia Care• Airway• Breathing• CirculationHow often should vitalsigns be assessed?
Postop SKIN Assessment “Altered Skin Integrity”• Day 3 or so to Day 14 (or 21 or more) – Proliferation: fibrin strands form scaffold • Collagen with blood = granulation tissue • Protect from damage or stress – No lifting, heavy exercise, driving etc. • At risk for dehiscence or evisceration• Day 15 (or weeks, months, years) – Scar is organized, less red, stronger – Max strength = 70 – 80%
Postoperative RESPIRATORY Assessment• Impaired gas exchange or impaired airway clearance• Risks: pneumonia, atelectasis• Assessment: – Open airway – Pulse oximetry (what is normal?) – Check opioid use (why?) – Monitor quality & quantity of respirations
Postoperative RESPIRATORY Assessment• Interventions: – Turn (also relates to cardiovascular risk – any ideas?) – Deep breathe & cough – Incentive spirometry – In-bed exercises (see text) – AMBULATION!!
Purpose: Fully inflate lungs Incentive Spirometry before) (assess pain Sit up• Respiratory Therapy Exhale completely, then seal lips & breathe in slowly &• Patient Education deeply as much as possible; hold breath 3 sec. & exhale• Patient Performed Follow with deep cough• Every 4 hours when Do 5-10 times every hour! awake Clean mouthpiece with water & shake dry
Postop SKIN Assessment “Altered Skin Integrity”• Wound healing – How is the face healing time-line different from the foot?• OR to Day 2 (may 3-5) – Inflammation vs. infection • redness, pain, swelling, warmth • skin held together by blood clots & tiny new blood vessels – Avoid pressure/ be sure to splint
Postop CARDIOVASCULAR Assessment: Potential for hypoxemia• Think (hypovolemic) shock (hemorrhage) – Assessment:• Prevention of venous stasis – Who is at risk? – What should be done?
Avoiding Venous Stasis • Avoidance of positions leading to venous stasis • In Bed Exercises • Antiembolism stockings • Sequential Compression Device • When all is said & done,
Postop NEUROLOGIC Assessment• Assess cerebral function – Think elderly• Assess motor/sensory function
Postop F & E Assessment• Fluid Status – Intake – Output• Why would a postop client need an IV??
Postop GI Assessment• Nausea & vomiting• Assessment of peristalsis/paralytic ileus• Interventions: – N/G tube, GI rest (NPO), AMBULATION• Postop Diets – Why are clear liquids usually the first diet? – What does “advance as tolerated” mean? – What are nursing responsibilities??
Postoperative Diets• 1. Clear Liquid• 2. Full Liquid• 3. Soft• 4. Regular• Postop Diets – Why are clear liquids usually the first diet? – What does “advance as tolerated” mean? – What are nursing responsibilities??
Postop SKIN Assessment “Altered Skin Integrity”• R edness• E dema• E cchymosis• D rainage• A pproximation• Is a scar as strong as the original skin?
The Ultimate in “Altered Skin Integrity”• Risk factors: - -Dehiscence -Evisceration• Prevention: -Wound Splinting -Abdominal binder -Diet
Postop PAIN Assessment (Chart 19-5, Chapter 7 pp. 67, 74-80)• Opioids (think____)• PO (who can’t take this?)• IM or sub cu (any problems here?)• IV injection
Postoperative Pain Relief (cont)• PCA – Review research – Can children use?• Epidural Analgesia• Spinal analgesia (intrathecal) – Used for postop pain – Usually morphine, fentanyl or dilaudid – Administered same time/same place as spinal anesthetic – Duramorph = 12 -24 hours
Medical-Surgical Nursing: AnIntegrated Approach, 2E PAIN Chapter 14 MANAGEMENT
Pain• An unpleasant sensory sensory and emotional experience associated with actual or potential tissue damage.• Whatever the client says it is, existing whenever the client says it does.
Nature of Pain• A major function of pain is to signal ongoing or potential tissue damage.• Pain can also be a protective mechanism against further injury.
Types of Pain• Pain Categorized by Origin.• Pain Characterized by Nature.
Pain Characterized by Origin• Cutaneous Pain (caused by stimulation of the cutaneous nerve endings in the skin).• Somatic Pain (nonlocalized and originates in support structures such as tendons, ligaments, and nerves).• Visceral Pain (discomfort in the internal organs).• Referred Pain (originating from the abdominal organs).
Pain Characterized by Nature• Acute Pain: Sudden onset, relatively short duration; mild to severe intensity; steady decrease in intensity over days to weeks.• Chronic Pain: Long-term (lasting six months or longer), persistent, nearly constant, or recurrent pain that produces significant negative changes in the client’s life.
Physiology of Pain• The body cannot sustain the extreme stress response of pain for more than short periods of time.• The body will conserve its resources by adapting even in the face of continuing pain of the same intensity.
The Gate Control Theory of Pain• Theorizes that person experiences pain with combination of these processes: – Sensory. – Motivational-Affective. – Cognitive.
Conduction of Pain Impulses• Transduction (stimulus triggered).• Transmission (impulse travels to spinal cord).• Perception (neural message converted into subjective experience).• Modulation (pain transmitters selectively inhibited).
Factors Affecting Pain Experience• Age.• Previous Experience with Pain.• Cultural Norms.
Assessment: Subjective Data• Location of pain.• Onset and duration.• Quality.• Intensity (on a scale of 1 to 10).• Aggravating and relieving factors.• How pain affects the activities of daily living.
Assessment: Objective Data• Physiologic (Acute pain involves elevated respiratory rate and blood pressure; pallor; dilated pupils, etc. Chronic pain shows adaption).• Behavioral (Acute pain behaviors include crying, moaning, clenched fists, etc. Chronic pain behaviors include depression, listlessness, loss of libido and weight).
Nursing Diagnoses• Two primary diagnoses used to describe pain are acute and chronic.
General Principles of Pain Relief• Individualize the approach.• Use a preventive approach.• Use a multidisciplinary approach.
Nurse’s Role in Administering Analgesics• Determine whether or not to give the analgesic.• Assess the client’s response to the analgesic.• Report to the physician when a change is needed.• Teach the client and family regarding the use of analgesics.
Principles of Administering Analgesics• Preventive approach.• Titrate to effect.
Preventive Approach• Pain is much easier to control if treated when it is anticipated or at a mild intensity.• Two methods of preventive approach are ATC (around the clock) and PRN (“as required”).
Titrate to Effect• The analgesic regimen needs to be titrated until the desired effect is achieved.• This involves adjusting the following: – Dosage. – Interval. – Route . – Choice of drug.
Three Classes of Analgesics• Nonopioid.• Opioid.• Analgesic adjuvants.
Reframing• Teaching clients to monitor their negative thoughts and replace them with ones that are more positive.
Guided Imagery• Using one’s imagination to provide a pleasant substitute for the pain.
Biofeedback• A process through which individuals learn to influence their physiological responses to stimuli.
Cutaneous Stimulation• The technique of stimulating the skin to control pain.• Includes: – Heat and cold application. – Cryotherapy (cold applications) – Acupressure and massage. – Mentholated rubs. – Electrical Nerve Stimulation.
Transcutaneous Electrical Nerve Stimulation• The process of applying a low-voltage electrical current to the skin through cutaneous electrodes.
Other Noninvasive Pain Interventions• Psychotherapy (including hypnosis).• Exercise.• Positioning and Body Alignment.
Invasive Pain Interventions• Used when noninvasive and pharmacological measures do not provide adequate relief.• Include: – Nerve block. – Neurosurgery. – Radiation therapy – Acupuncture.