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					1   Nursing care of the Perioperative Client
    Fall 2006
2   M.N., female client age 40, is admitted to the med-surg unit with acute
    cholecystitis characterized by RUQ (right upper quadrant) pain, elevated
    WBC’s and pyrexia (fever) of 102 degrees. A surgical consultation is
    obtained and the nurse prepares the client for surgery…...

3   Reasons for surgery (table 20-1)
    • Diagnostic
        • Origin and cause of disorder
           • biopsy
    • Curative
        • Correct a health problem
           • mastectomy
    • Restorative
        • Improve functional ability
           • TKR
    • Palliative
        • Relieve symptoms but not correct disorder
           • colostomy
    • Cosmetic
        • Enhance personal appearance
           • Revision of scars

4   Categories of Surgical Procedures (table 20-1)
    •   Reason
    •   Urgency
    •   Degree of risk
    •   Anatomical locale
    •   Extent of surgery req’d

5   How would you classify M.N.’s surgery and why?

6   Urgency of Surgery
    • Elective
        • planned, nonacute
            • Total joint replacement
    • Urgent
        • requires prompt intervention; may be life-threatening if left untreated
            • Bone fracture
    • Emergent
        • requires immediate intervention to prevent permanent disability or death
            • Gunshot / stab wound

7   How would you describe the urgency of M.N.’s surgery and


8    Degree of Risk
     • Minor
          • without significant risk
          • local anesthesia
          • may be performed in ambulatory setting
             • CVAD, PPM, AICD
     • Major
          • greater risk, more extensive
          • performed in acute care setting
             • MVR, CABG

9    How do you consider the degree of risk for M.N.’s surgery
     and why?

10   Collaborative care in the preoperative setting

11   Components of Preoperative Assessment:History Taking
     •   Age
     •   medication and substance use
     •   medical history
     •   presence of allergies
     •   surgical history and use of anesthesia
     •   family history of response to anesthetics
     •   availability of autologous blood
     •   religious objections to receipt of blood products

12   Components of Preoperative Assessment:History Taking
     • Discharge planning concerns
          • home environment
          • availability of support
          • follow-up care concerns

13   Selected Risk Factors that Increase Postoperative
     • Age > 65 years
          • increased age increases risk of altered immune response and healing
     • Medication and Substance Use
          • ETOH abuse effects coagulation and response to analgesia

           • Tobacco use increases respiratory complications
           • OTC, herbal therapies and Rx medications may result in complications

14   Selected Medications that Increase Surgical Risk
      • Antihypertensives
           • may cause hypotensive crisis
      • Anticoagulants, NSAIDS & Aspirin
           • increase risk of hemorrhage
      • Antidiabetic agents
           • increase risk for hypoglycemia
      • Corticosteroids
           • delays wound healing, mask infection, may increase serum glucose, increase risk for bleeding

15   Selected Risk Factors that Increase Postoperative
      • Co-morbitity
           • Cardiovascular risk factors
              • CAD, HTN, Dysrhythmia, Valve Disease, CHF
           • Respiratory risk factors
              • COPD, tobacco use
           • Renal/urinary risk factors
              • renal insufficiency, oliguria, polyuria, dysuria, nocturia
           • Neurological risk factors
              • Cognitive, motor and sensory deficits

16   Selected Risk Factors that Increase Postoperative Complications
      • Musculoskeletal risk factors
           • deformities, arthritis, presence of prosthesis to prevent perioperative positioning injury and electrical burn
      • nutritional risk factors
           • malnutrition, obesity
      • psychosocial risk factors
           • fears, anxiety, previous experience with surgical interventions
      • presence of allergy to latex and iodine
      • family history of intolerance to anesthesia
           • malignant hyperthermia

17   What systems of communication are utilized to elicit data from M.N. that
     would support the existence of these risk factors and how do they help
     identify these concerns?
18   Laboratory tests/diagnostics to identify potential risks
      •   Basic metabolic panel (BMP)
      •   CBC
      •   PT/PTT
      •   urinalysis
      •   Type and screen vs. Type and crossmatch
      •   additional panels as indicated
           • LFTs, amylase, lipase
              • (based on history, presenting illness)
      • EKG
      • chest Xray
      • pulse oximetry/ABG’s (as indicated)

     • radiological studies (CAT scan, MRI etc…….)

19   M.N.’s Lab results
     •   Na:                          135
     •   K:                           3.2
     •   BUN/Creat ratio:       WNL
     •   U/A:                   + leukocytes
     •   Pulse Ox:              90% on room air
     •   EKG:                   RRR 98
     •   CXR:                   possible small RLL                infiltrate, inadequate
                                chest expansion

20   Based on that data:

     •   What are your concerns?
     •   What reference would you use to better understand the client’s situation?
     •   What other data do you need?
     •   What would be your priorities in examining the client?
     •   What systems would you perform a physical examination on?

21   Role -play notifying the physician...
22   Collaborative care: Anticipating MD orders
     T.O. Dr. Jones/S Sinclair RN
     • ABG’s stat on room air
     • 2 lpm NC; titrate to keep SaO2>93%
     • IS 10 X per hour WA
     • Cipro 400 mg IVPB stat and q 12 hrs
     • change IV to 1 liter D51/2NS with 20meq KCL at 150 cc/hr

23   The client, M.N., is evaluated by the surgeon, surgery is scheduled
     for the am.
     The order reads:
     consent: laparoscopic cholecystectomy/ possible open, possible
     exploratory laparotomy
24   Consent overview
     •   Implied consent
     •   Signed consent
     •   Telephone consent
     •   Health care proxy consent
     •   Administrative consent
     •   Situations when clients are unable to sign:
          • Can understand:
          • Can’t understand:

     • You, as the RN, are not responsible for providing detailed info. about the surgery.

     • The role of the RN is to clarify facts that have already been presented by MD.

26   Preoperative planning
     • Identification of complications
        • nurse must assess for presence of risk factors unique to the client’s stressor
     • ensuring informed consent
        • surgeon obtains consent
        • RN witnesses that the client signs the form
     • implementing dietary restrictions
        • MD must specify if NPO (….except meds)
                   meds, when given, with sips of water only

27       Preoperative planning
     • Assessing routine medications

     • initiation of surgical preps
        • routine bowel preps
        • skin prep

     • insertion of tubes/drains/vascular access
        • IV, F/C, NGT

     • administration of preoperative medications

     • completion of preoperative checklist

28   Preoperative Teaching
         what are we trying to prevent??????
     • Diaphragmatic breathing
        Incentive spirometry
        Coughing and splinting / C&DB
               pneumonia / atelectasis
     • Leg exercises
        Use of sequential TEDS post- op
               venous pooling / thrombophlebitis
     • ROM and early ambulation
               same as above + constipation
     • Anxiety management

29   M.N.’s transfer summary
     M.N. is a WD, WN 40 y/o female who presented to the ER with RUQ pain and admitted to the med/surg unit
     with acute cholecystitis. No prior med/surg history. Denies allergies. Abd pain persists 6 on scale 0-10 with no
     rebound tenderness. Abdomen flat, + BS in all quads. No c/o SOB or CP. Resp even and unlabored, NAD. S1,
     S2, no murmur. Lungs CTA, diminished at right base. CXR RLL inf iltrate.. Performing IS and C&DB exercises
     q 1 hr. Pulse ox 96% on 2lpm NC. K+ 3.2, receiving 1 L D51/2NS with 20meq KCL infusing via pump at
     150cc/hr to #18g PIV (L)AC. UA +leukocytes,started on Cipro IVPB. Consent obtained, preop checklist

     complete, teaching initiated: see flowsheet. NPO after MN as ord ered. 1000 meds given @0600 as per MD.
     Transferred to OR via stretcher at 0700 hrs. MD aware of above findings with orders followed.

30   Collaborative care in the intraoperative setting
31   Members of the Surgical Team
     • Surgeon and surgical assistant
                   • MD, PA, intern, resident, fellow, surg tech
     • anesthesiologist and nurse anesthetist (CRNA)
     • RN First Assistant (RNFA)
     • Registered Nurse specialists
                   • Holding area RN, circulating RN, scrub RN

32   Registered Nurse specialists
     • holding area nurse
        • presurgical assessment/procedures & initiation of operative report
     • circulating nurse
        • oversees/coordinates care in OR suite
           • Traffic cop, communicator, reporter, documentor
        • I/O, provides supplies/equipment, count, reports to PACU RN. etc
     • scrub nurse
        • drapes, maintains sterile field, provides surgical instruments, count, etc.
           • Maintains count of equipment used
     • specialty coordinator nurse


34   Perioperative Area Layout
     • Traffic Flow
        • Unrestricted
        • Semirestricted
        • Restricted

           • Situated close to ICU, blood bank, lab and pathology depts.

           • Why are we so concerned about flow????
                 Reduction of contamination from outside to OR suite
                    …….prevention of nosocomial infection


36   Safety and Security in the Perioperative Area
     • Prevention of Infection Transmission
        • surgical attire donned in OR locker room
           • shirt, pants, cap, protective cover jacket, no jewelry
        • attire when entering OR suite with sterile field
           • shoe covering, mask, cap, cover jacket if not “scrubbed in”, eye wear if necessary
        • surgical scrub
           • surgeon, ORT, scrub nurse use disposable scrub brush from fingertip to elbow 3-5 minutes and rinse with elbows down

37   Types of Anesthesia

     • General
     • local/regional
     • Conscious sedation


39   General Anesthesia
     • CNS depression
         • analgesia
         • amnesia
         • unconsciousness
            • loss of muscle tone and reflexes
     • two methods
        • inhalation gases
        • IV injection
        • balanced anesthesia uses both
     • requires mechanical ventilation

     • Review table 21- 1,21-2, 21-3,21- 4 in text!!!!!!
         (For 5th edition)

40   Adjuncts to General Anesthesia
     • Hypnotic: Versed (benzodiazepine)
         • amnesia, Antianxiety, sedative, muscle relaxant
            • can cause respiratory depression, apnea
            • reversed with Romazicon

     • Opioid Analgesics: Fentanyl (sublimaze)
         • postoperative analgesia, anesthetic at higher doses
            • respiratory depressant, decreases alveolar ventilation
            • reversed with Narcan

41   Adjuncts to General Anesthesia
     • Neuromuscular blocking agents
         • act on skeletal muscle
     • two types
         • nondepolarizing: Pavulon
            • block acetylcholine
            • reversed with neostigmine and atropine
         • depolarizing : succinylcholine
            • excessive salivation increases risk for aspiration

42   Complications of General Anesthesia
     •   Overdose
     •   unrecognized hypoventilation
     •   complications of intubation
     •   side effects of selected agents
     •   Malignant hyperthermia

     • Positioning injury

43   Malignant Hyperthermia (MH)
     •   Genetically predisposed client
     •   increased intracellular calcium in skeletal muscle is triggered by anesthetic agents
     •   elevated calcium results in increased metabolism, increased BMR
     •   leads to acute, life-threatening increase in body temperature, hyperkalemia, acidosis

44   Clinical Manifestations of MH
     • Immediately after induction or rarely after anesthesia is terminated:
         •   Tachycardia, hypotension,tachypnea
         •   muscle rigidity
         •   dark colored urine
         •   decrease in O2 sat
         •   elevated body temperature….late sign !!
     • treated with a skeletal muscle relaxant
         • Dantrolene direct IV
         • Body temp cooling
         • IVF hydration

45   Local or Regional Anesthesia

     • Temporarily interrupts the transmission of sensory nerve impulses from a specific area or
         •   Motor function may or may not be affected
         •   Client does not lose consciousness
         •   Gag reflex remains intact
         •   Supplemented with sedatives, opioids, or hypnotics
         •   accomplished through topical application or local infiltration

46   Types of Anesthetic Approaches/agents
     • Nerve Block
         • into or around a nerve or nerve group
     • Spinal Anesthesia
         • subarachnoid space
     • Epidural Anesthesia
         • epidural space
     • Use of lidocaine or Marcain

47   Complications of Local/Regional Anesthesia

         • Anaphylaxis
         • Edema and Inflammation
         • Systemic absorption
              • Systemic Toxic Reaction
              • CNS stimulation followed by CNS and Cardiovascular collapse
              • treated with barbiturate
         • Overdosage
         • Positioning injury

48   Conscious Sedation

     • Administration of IV sedative, hypnotic, and Opioid medications.
         •   Produces a depressed level of consciousness
         •   Retains ability to maintain a patent airway
         •   Able to respond to verbal commands or physical stimulation
         •   Used for relatively short procedures
     • agents may produce respiratory and cardiac side effects

49   M.N. presents to the OR to undergo an open
     cholecystectomy and is met by the circulating nurse in the
     holding room.
50   Collaborative care
     • Identification using name band
                     • What do we check ????

     • Review of medical records
         •   consent
         •   H&P
         •   allergies/previous reactions to anesthesia
         •   presence of autologous blood bank and availability of blood products
         •   lab and diagnostics

51   Planning Care:Selected diagnoses
     • Collaborative Problems: Hypoventilation/risk for aspiration
        Hypovolemia / Hemorrhage
     • Risk for perioperative positioning injury
     • Risk for injury
     • Impaired skin integrity/impaired tissue integrity (EBP - self study in text p.335)

52   Hypoventilation
     • Assess for the presence of s/s of hypoventilation
         • respiratory rate, rhythm, adequacy of chest expansion, skin color, tachycardia
     • Continuous pulse oximetry, cardiac monitoring, end tidal CO2 monitoring

53   Risk for aspiration
     • Position HOB elevated
     • Suction oral secretions prn
     • Mon respiratory status frequently
     • Mon for paralytic ileus and insert NG tube as ordered to reduce gastric pressure
       and reflux
     • Proper oral care

54   Hypovolemia

     • Assess for the presence of s/s of deficient fluid volume
          • decrease urine output
          • excessive blood losses
          • tachypnea,tachycardia, hypotension, thready peripheral pulses
     •   Continuous cardiac monitoring, NIBP, accurate I/O
     •   Mon electrolytes, Hgb/Hct
     •   Replace losses intravenously
     •   Use blood salvaging equipment when indicated
     •   Administer blood products as ordered


56   Risk for perioperative positioning injury interventions
     •   Determine if pre-existing condition exacerbates risk
     •   Maintain physiological alignment
     •   protect circulatory and respiratory function
     •   protect neuromuscular and skeletal structures
     •   Protect eyes and ears from injury
     •   consider comfort,safety and dignity
     •   ensure adequate access for team
     •   Document position and safety measures used
     •   Change positions slowly to prevent hypotension
     Review common surgical positions figure 21-12 and intervention to prevent injury table 21 -6

57   Risk for Injury
     • Ensure client safety from electrical hazards
     • perform operating room count of surgical equipment according to AORN

58   M.N. undergoes an open cholecystectomy and is transferred
     to the PACU...
59   The PACU nursing note:
         Rec’d to PACU, supine, breathing spontaneously through OETT #7.5F, 21cm @ (L) corner.
     RR 18 even, shallow. NAD. Lungs CTA, diminished at bil. bases. On 35% O2 via humidified T
     piece. pOx 94%. Asleep, easily arousable to verbal stimuli. Sterile Dsg to RUQ CDI. JP drain
     in Anterior RUQ to compression drainage; 15 cc sanguinous drainage. NGT to LCWS - 20 cm,
     no drainage noted. F/C 16 Fr to BSD 200 cc amber urine emptied. IV D5 0.9%NS at 125 cc/hr
     via #18 (L)AC. RST 92, on CM. BP ®120/60 temp 96.9 degrees. +2 DP pulses bilaterally. Skin
     pink, warm, dry. HOB elevated to 45 degrees. Warm blankets applied. See flow sheet.

60   Postanesthesia Recovery Score (Modified Aldrete Score)

            2 = Fully awake
     1 = Responds to name
     0 = No response
     Activity on command
            2 = Moves all extremities
     1 = Moves two extremities
     0 = No movement
            2 = Free deep breathing
     1 = Dyspneic, hyperventilating, obstructed breathing
     0 = Apneic

           2 = Blood pressure within 20% of preop level
     1 = Blood pressure within 50-20% of preop level
     0 = Blood pressure 50%, or less, of preoperative level
     Oxygen saturation
           2 = SpO2 > 92% on room air
     1 = Supplemental O2 required to maintain SpO2 > 92%
     0 = SpO2 < 92% with O2 supplementation

61   Focused Assessment in PACU
     • Post anesthesia recovery scale
          • can not be discharged from PACU unless meets or exceeds preoperative score
     • airway assessment, Cardiac monitoring, pulse oximetry, VS measurement
          • monitored continuously and recorded every 10-15 minutes according to policy
     • Restoration of normal body temperature
          • use of active external rewarming
               • bair hugger
     • strict I/O to identify fluid imbalance

62   Focused Assessment in PACU
     • peripheral vascular assessment
          • initiation of antithrombotic therapy
     • Neurovascular exam
        • return of neurological function in case of general and spinal anesthesia
     • Gastrointestinal exam
        • presence of nausea and vomiting, return of BS
     • integumentary exam
          • surgical site assessment
     • pain assessment
          • initiation of PCA or epidural analgesia

63   Planning Care
     •   Potential for: Hypoventilation / Hypoxemia
     •   Risk for ineffective respiratory function
     •   Potential for: Hypovolemia / Hemorrhage
     •   Potential for: Dysrhythmia
     •   Potential for: DVT / PE
     •   Risk for hypothermia
     •   Impaired skin integrity
     •   Acute Pain
     •   Risk for injury

64   Post operative care

     • review pt. handouts :post-op plan of care
     • Review post-op teaching plan

       Case study 2 page 109
     Winningham and Preusser

               • We already began this!!!!!!

65   How to approach case studies
     •   Review the case study scenario and have your text, tabers, drug guide, clinical skills book and Ackley with you to be readily accessed
          • Do a content map and restate in your own words the content map for each of the following:
              • Post –op care open cholecystectomy
              • Nasogastric suctioning
              • Intravenous potassium replacement
              • Morphine sulfate 10mg IM q 4
              • Ampicillin 2gm IVPB q 6 hrs
          • Read through each collaborative problem/diagnoses and mark the page to access later for review
          • Read all the questions:
              • Did something come up that you did not address in your content maps?
              • Review how you approached your content map development and refin e it.
          • Answer all the questions and compare answers with a peer
              • What were some of the strengths of your work?
              • What could you do more effectively the next time you work on a c ase study?


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