PERI-OPERATIVE NURSING Perioperative Phases • Pre-operative • Intra-operative • Post-operative Describe each of these stages? What are the essential nursing competencies for each phase? (Nursing Responsibilities: Chart 18-1, p. 482-483) Review Operative Classifications Operative Categories • Diagnostic • Emergent • Curative • Urgent • Reparative • Required • Reconstructive/cosmetic • Elective • Palliative • Optional (Table 18-1, p. 485) Ambulatory Surgery How is ambulatory surgery defined? What is the goal of ambulatory surgery? What are the nursing responsibilities associated with ambulatory surgery? Pre-operative Phase • PAT (blood tests, x-rays, other diagnostics) • Teaching • Knowledge of Risk Factors for Complications (Chart 18-3, p. 486) Important Things to Consider Preoperatively • Stop ASA 7-10 days before surgery • Stop herbals 2-3 weeks before surgery • Encourage no smoking for 4-8 weeks before surgery; stop smoking at least 24 hours before surgery • Monitor immunocompromised patient closely for s/s of infection before surgery • Surgery contraindicated if acute renal problems • Control hypertension prior to surgery if possible • Obesity increases risk and severity of complications Disease/Medication Specific Considerations • Diabetes Mellitus: – At risk for hyperglycemia or hypoglycemia • Long-term corticosteroid use: – At risk for adrenal insufficiency • Uncontrolled Thyroid Disease – Overactive: risk of Thyrotoxicosis – Underactive: risk of respiratory depression Considerations for the Elderly • Increased risk for complications – Less physiologic reserves • “Hazards. . . are proportional to the # and severity of c0-existing health problems and the nature and duration of the operative procedure.” (p. 491) Pre-Operative Teaching • Reinforce physician’s explanations and instructions • Discuss what to expect • Instruct in breathing and leg exercises • Demonstrate splinting of abdomen (if appropriate) • Explain rationale for frequent position changes • Discuss pain management • Discuss cognitive coping strategies Miss Nervous Nellie • Miss N is scheduled for a colon resection. A recent biopsy of a polyp revealed a malignancy. During your pre-admission interview Miss N is tearful and keeps saying “I hope this won’t be like it was when my dad had colon surgery.” “I’m so afraid I will die just like he did.” What are Miss N’s psychosocial needs? How will you meet those needs? Pre-Operative Care General Immediate • Protect from injury • Gown – 7 patient safety goals (JCAHO) • Cap (braid long hair, no hairpins) • Manage nutrition and fluids • Remove dentures/plates – NPO • No jewelry • Prepare bowel (if appropriate) • Void immediately before • Prepare skin (if appropriate) transport • Cover with bath blanket • Administer preanesthetic medication if ordered Responsibilities related to the Medical Record • Complete pre-operative check list • Place surgical consent form in plain view • Send entire medical record (chart) to surgery with patient – Includes current MAR Informed Consent • What is it? • When is it necessary? • Who can sign? • What is the responsibility of the nurse? • What are the legal implications? Holding Area Responsibilities • Initiation of verification form • Pre-anesthesia medication if ordered • Foley catheter if ordered Note: Entire peri-operative team should be involved in verification process (correct patient, correct site, etc) Why is the verification process so important? Family Needs • Explain where to wait • Surgeon will talk to them after surgey • Never judge seriousness by length of time patient in surgery (keep family updated) • Prepare them for what they will see post-op • Explain post-op protocol and routines Intraoperative Phase An interdisciplinary approach to intraoperative care is essential. Who makes up the interdisciplinary team? What are the responsibilities of team members? Microbe Management • Controlled Environment What measures are implemented to control the surgical environment? Discuss the use of zones to decrease mibcrobes. • Surgical Asepsis List the basic principles of aseptic technique. Intraoperative Case Study The client, a 62-year-old secretary, has entered the surgical suite about 30 minutes after she has received atropine and midazolam for preoperative medication. The OR schedule lists that she is scheduled to have a vaginal hysterectomy. In addition, the preoperative history indicates that she smokes three packs of cigarettes per day and drinks three cans of beer each day. When you ask her what kind of surgery she is having today, her response is “I am going to have a hemorrhoidectomy.” You ask her if she means hysterectomy and she responds, “Well, it is some kind of operation ‘down there’.” What Should You Do? • What additional questions should you ask this client? • What should you do with the information? • What effect, if any, will her history of smoking and drinking have on her surgical experience? The Case Continues The client demonstrates understanding of the surgical procedure and the team proceeds with the planned vaginal hysterectomy. The client weighs 96 pounds. • In what position should you place this client for the surgical procedure? • What areas on this client are most likely to be injured as a result of poor positioning or inadequate padding? Health Hazards Associated with Surgical Environment • Laser Risks • Exposure to blood and body fluids • Latex allergy Types of Anesthesia • General – 4 stages • Regional – Epidural – Spinal – Local conduction block • Moderate Sedation/Analgesia • Monitored Anesthesia Care • Local Anesthesia Potential Intraoperative Complications Nausea and vomiting Anaphylaxis Respiratory complications Inadequate ventilation, airway occlusion, intubation of the esophagus, and hypoxia Hypothermia Malignant hyperthermia Disseminated Intravascular Coagulation What are measures to prevent or treat these complications? Postoperative Pain Control • What is the definition of Pain? • As nurses, what do we need to remember about the pain experience? • What is the key reason to control postoperative pain? Opioid Analgesics • Commonly prescribed for postoperative pain and immediate postoperative restlessness. • Why would this drug be effective for restlessness? • By what route will this drug be adminstered? Patient Controlled Analgesia • What is a nursing responsibility with PCA? • What is the benefits of self administration of analgesia? • What are the two requirements for use of PCA? Epidural Infusions • What is an epidural infusion? • Why would an epidural infusion be used? • When must epidural infusions be used cautiously? Intrapleural Anesthesia • What does intrapleural administration mean? • What are the benefits to intrapleural anesthesia? Other Pain Relief Measures • Subcutaneous Pain Management Systems • Nonpharmacologic Measures Postoperative Care: PACU • What is the goal of PACU care? • What does PACU care entail? Immediate General Floor Postoperative Care • What is included in the immediate post- operative care of the individual? • How often should vital signs be assessed? • What other assessments are needed? • What should you do if the systolic pressure is • < 90 mm HG? Post 24 hour Postoperative Care • How does the focus of care shift after the first 24 postoperative hours?
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